9/10/19
The Red, The Cloudy, The Painful
David A. Wilkie DVM, MS, Diplomate ACVO Professor Emeritus The Ohio State University [email protected]
The eye is the “window” to systemic information Uveitis
n Clinical Signs n Anterior n Posterior
The eye has the highest blood flow by weight of any organ
Anterior Uveitis Anterior Uveitis
n Miosis n Miosis n Flare
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Anterior Uveitis
n Miosis n Flare n Redness
Anterior Uveitis Anterior Uveitis
n Miosis n Miosis n Flare n Flare n Redness n Redness n Photophobia n Photophobia n Pain
Anterior Uveitis Anterior Uveitis n Miosis n Flare n Miosis n Redness n Flare n Photophobia n Redness n Pain n Photophobia n Keratic precipitates n Pain n Keratic precipitates n Hypotony
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Posterior Uveitis Anterior Uveitis
n Chorioretinitis n Etiologies n Hemorrhage n The etiologies of anterior uveitis can n Vaculitis be either ocular or systemic. n Edema n Transudate n Exudate Ocular Systemic
Uveitis
Anterior Uveitis Anterior Uveitis n Ocular Etiologies n There are only 4 main ocular n Ocular: causes, rule them out first n Corneal ulceration
Anterior Uveitis Anterior Uveitis
n Ocular: n Ocular: n Corneal n Corneal ulceration ulceration n Lens-induced n Lens-induced n Ocular trauma
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Anterior Uveitis Anterior Uveitis n Ocular: n Corneal n Neoplasia ulceration n Primary vs secondary n Lens-induced n Ocular trauma n Neoplasia
n primary Ciliary adenoma
Lymphosarcoma
Anterior Uveitis
n Etiologies Uveitis n The etiologies of anterior uveitis can Bacteremia be either ocular or systemic. Septicemia Viremia Mycotic Metastatic neoplasia Ocular Autoimmune X Systemic
Uveitis
Anterior Uveitis Uveitis n Systemic Etiologies: n Bacteremia, viremia, or septicemia n Autoimmune n Where does you patient live? n Metastatic neoplasia n Travel history? n A complete physical examination is therefore essential.
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Blasto Heartworm Canine Uveitis Lyme
n Idiopathic / Immune-mediated (58%)
n Neoplasia (24.5%) Lymphosarcoma Histiocytic Sarcoma n Systemic infectious disease (17.5%)
Multiple myeloma Erhlichia
Massa KL, et al. Causes of uveitis in dogs: 102 Cases (1989-2000) Veterinary Ophthalmology
Uveo-Dermatologic Syndrome Erlichia
Blastomycosis Cryptococcosis
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Cryptococcosis Canine Rocky Mountain Spotted Fever
Optic neuritis
Parasitic Migration Angiostrongylus
Courtesy of Dr. Tim Knott
Ocular Oncology Systemic Infectious Disease n Other n Protothecosis
n Aspergillosis Primary - intraocular Secondary - intraocular n Bartonellosis Melanoma Lymphosarcoma Adenoma/Adenocarcinoma Carcinoma n Infectious Canine Hepatitis Spindle cell sarcoma - cat Sarcoma n Brucella canis n Lymes disease
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Canine Neoplastic Uveitis Multiple Myeloma
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Canine Neoplastic Uveitis Lymphosarcoma Histiocytic Sarcoma
Feline Uveitis Feline Infectious Disease n Idiopathic / Immune-mediated (33-58%) n Neoplasia (13-23%) • FELV (12%) Cat may have more than one of these n Systemic infectious disease (24-83%) • FIP (5-19%) • Toxo (5-75%) • FIV (13-21%) • Crypto (2%) • Bartonella
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Crypto FIP Anterior Uveitis - systemic
n Diagnostic Tests Toxo n History - Duration, progression of disease n Physical examination n Complete blood count n WBC count, Differential FIP n Platlet count FeLV FIV
Anterior Uveitis Anterior Uveitis n Diagnostic Tests n Biochemical profile n Serology – REMEMBER CO-INFECTIONS n Serology n Blasto, Histo, Crypto n Radiology n RMSF, Erlichia canis/platys, Lymes, ICH, n Ultrasound Distemper n Cytology/Histopathology n FeLV, FIV n Toxo - request IgG, IgM, and Toxo antigen tests n Bartonella n Leishmania
Uveitis - Things to remember Sequelae of Anterior Uveitis
n Canine uveitis n Feline uveitis n Anterior &/or posterior synechia n Idiopathic (58%) n Idiopathic (33-58%) n Cataract n Neoplasia (24.5%) n Neoplasia (13-23%) n Systemic infectious n Systemic infectious n Glaucoma disease (17.5%) disease (24-83%) n Blindness n Phthisis bulbi
Therefore, in approximately 50% of cases in both dogs and cats, there is a systemic disease causing the uveitis.
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Glaucoma Glaucoma
n Is the glaucoma primary or secondary?
Intraocular Pressure Glaucoma Determination n Is the glaucoma primary or secondary? n There are 3 specific ways to determine n Is it acute or chronic? intraocular pressure: n Indentation tonometry n Applanation tonometry n Rebound tonometry Acute Chronic
Glaucoma
Primary Glaucoma Primary Glaucoma
n This is generally seen in predisposed n Not associated with breeds: any other ocular n Poodle, Basset hound, Beagle, Afghan disease n American & English Cocker Spaniel n No antecedent n English Springer Spaniel cause n Artic breeds - Husky, Elkhound, Samoyed, etc. n Shar-Pei, Chow Chow, Dalmation, Bouvier, Other
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Primary Glaucoma Primary Glaucoma n predisposed to bilateral involvement n predisposed to bilateral involvement n bilateral involvement is 50% within 2 n bilateral involvement is 50% within 2 years years n unaffected eye requires preventive therapy n IOP monitoring n Prophylactic Rx
Secondary Glaucoma Secondary Glaucoma n The result of some other event in the n Etiologies eye which results in a decrease in n Anterior lens aqueous humor access to the drainage luxation angle or a decrease in outflow
Secondary Glaucoma
n Gene for PLL identified at University of Missouri and AHT n Simple recessive trait n Homozygous affected luxated by 4-8 yr n 30% develop glaucoma
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Secondary Glaucoma Secondary Glaucoma n Etiologies n Etiologies n Anterior lens n Anterior lens luxation luxation n Synechia n Uveitis
Hypermature cataract, Lens-induced uveitis, Secondary glaucoma Secondary Glaucoma
n Etiologies - PIFM n Pre-iridal fibrovascular membrane n Uveitis #1 n Intraocular Neoplasia n Retinal Detachment
Why does this happen? PIFM
Normal Iris
PIFM
§Chronic uveitis §Intraocular neoplasia §Retinal detachment/degeneration
Glaucoma PIFM’s
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Acute Primary Glaucoma Infarction Redness secondary to Deep corneal vessels acute glaucoma Dilated Pupil Diffuse Corneal Edema
Acute Glaucoma Acute Glaucoma
n Treatment n Treatment n Personal preference: n Prostaglandins n Latanoprost n Latanoprost n Mannitol if 0.005% (Xalatan) latanoprost ineffective Miosis n Topical and Systemic CAI n Referral for Sx
Passive Paracentesis – 30 guage needle Acute Glaucoma
n Treatment n Topical CAI’s
Dorzolamide reaction
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Acute Glaucoma n TransScleral CycloPhotocoagulation
TSCP Success at 1 year: Canine: 50-60% Equine: >80%
Endocyclophotocoagulation (ECP) Lens Laser targets Ciliary Processes Success at 1 year: Canine: >80%
Iris
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Success at 1 year: Canine: >80%
Ahmed glaucoma shunt
Chronic Glaucoma n These are not emergencies as is the case with the acute patient n Treatment n Prosthesis n Enucleation n Pharmacologic ablation
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Chronic Glaucoma K9 Intrascleral Prosthesis n Treatment n Eviseration with Prosthesis n Remove internal contents of the globe n Insert a 19mm silicone sphere n Cornea will vascularize over the next 2-4 weeks.
http://youtu.be/lF0bOb42oNs
K9 ISP 1 week post-op K9 ISP 2 week post-op
K9 ISP 10 week post-op K9 ISP 1 year post-op
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K9 ISP OU 2 yr post-op K9 ISP OD, enucleation OS 1 yr post-op
Cataract Etiology of Cataracts
n Hereditary Canine n Metabolic n Inflammatory Feline n Traumatic n Toxic n Nutritional n Radiation n Electric
Cataract - location Cataract - location n Location n Location n Capsular n Capsular n Cortical
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Cataract - location Cataract - location n Location n Location n Capsular n Capsular n Cortical n Cortical n Nuclear n Nuclear n Equatorial
Cataract Cataract - severity n Age of onset n Progression n Congenital n Incipient n at birth n Developmental
n < 6yr n Senile
n >6-9yr
Cataract - severity
n Progression n Incipient n Immature
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Cataract Equatorial vacuoles - immature
Cataract Cataract - severity Posterior cortical - immature
n Progression n Incipient n Immature n Mature
Cataract Mature cataract
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Cataract - severity Hypermature n Progression n Incipient n Immature n Mature n Hypermature
J. Mould
Hypermature Hypermature
Mature Hypermature Hypermature with Retinal detachment
J. Mould
Hypermature cataract with LIU Lens induced uveitis
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Lens induced uveitis with secondary glaucoma Ocular Ultrasound
Normal eye 10 mHz
Anterior Chamber Iris
Lens
Vitreous EOM
Cataract Surgery n Ultrasound Cataract n Vitreous Degeneration n Immature - 2% Vitreous degeneration n Mature - 7% n Hypermature - 20%
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Vitreous Cataract Surgery degeneration
n Ultrasound n Retinal Detachment n Immature - 2% n Mature - 5% n Hypermature - 12-15%
Cataract Cataract
Retinal Retinal detachment detachment
Cataract – why surgery? Retinal n 3 options for vision significant cataracts detachment n 1. Surgery – phacoemulsification + IOL n Best outcome
n 2. Anti-inflammatory treatment; No surgery n Failure 4x greater than #1
n 3. No treatment; No surgery
n Failure 255x greater than #1
n Failure 65x greater than #2
Lim C, et al: Cataracts in 44 dogs (77 eyes): A comparision of outcomes for no treatment, medical management, or phacoemulsification with IOL. Can Vet J 52:283-288, 2011
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When to Refer? Emmetropia n Referral should be done early n We no longer wait for a mature “ripe” cataract n Refer early immature and all cataracts that are Aphakia -14D progressive
Sir Harold Ridley 1 Year - old Dog Phaco -8 sec, 50ml
2 yr post op IOL’s AcriVet 60V IOL
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Questions?
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