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Home , Distichia, Lagophthalmos

9/2/15

Ophthalmic Emergencies

Jamie W. Herrmann, DVM Intern

Discussion Topics

v What is an ophthalmic emergency?

v Common reasons for presentation § Proptosis § “Bulging” or “swollen” eye § Acute eye pain § Acute blindness § “Red” eye § Ocular & periocular trauma § “Cloudy” eye

v Treatment of common diseases

Defining Ophthalmic Emergencies

v “True” emergency § Threatens integrity of the or visual pathway § Proptosis § Severe corneal injury § § Anterior luxation § Lid laceration

v “Prefergency” § What often comes in the door § § Superficial ulcer § Blindness § Anterior

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Defining Ophthalmic Emergencies

Many ocular diseases look identical v Most ocular disease are urgent • Visual pathway is extremely sensitive

Presenting Complaints for Common Ocular Emergencies Acute Eye Pain Cloudy Eye § § Glaucoma § Glaucoma § Anterior lens luxation § Anterior lens luxation § Anterior uveitis § Anterior uveitis Bulging/swollen Eye

Red Eye § Glaucoma § Glaucoma § § Orbital disease § Exophthalmos § Hypersensitivity (periocular) § § Uveitis Acute Blindness § § Glaucoma § (ulcers) § Retinal disease • SARDS, detachment, etc. § § Optic chiasm disease (tumor)

Emergency Proptosis

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Emergency Proptosis

Prognostic Indicators Overall Prognosis v Presence of vision = good v Brachycephalic dogs v Normal PLR = good § Guarded (30% regain vision) v Damage to ≥ 3 extraocular v Any other animal muscles = bad § Grave (pretty much 0%) v = bad v Desiccated = bad

Emergency Proptosis

Treatment v Globe reduction + v Topical antibiotics § Drops are easiest v Systemic antibiotics § Torn and rectus muscles v Anti-inflammatories § Prednisone is best v Analgesics § Tramadol, gabapentin, etc. v E-collar Correct placement of sutures is crucial

Emergency Proptosis

1) Dilute betadine 2) Lubricate 3) Lidocaine block

4) Pre-place sutures 5) Reduce globe 6) Tie sutures

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Emergency Proptosis

Corneal Ulcers

Causes of corneal ulcers

Decreased Increased corneal epithelial cell protection turnover

Tear film problems problems Endogenous Exogenous - Quantitative KCS - Lagophthalmos - - Trauma - Qualitative KCS - CN VII paralysis - Ectopic cilia - Foreign body - CN V paralysis - Distichia - Infection - - - Herpesvirus - Eyelid tumors

Schematic adopted from Slatter’s Fundamentals of Veterinary Ophthalmology, 5th Edition

Urgency Superficial Ulcer

Diagnostic Tests Foreign material v STT of both eyes v Fluorescein stain v +/- eye pressures Treatment v Antimicrobial TID or more § Neo/poly/bac ointment § Neo/poly/gram solution ($$$) - Pain control if needed - 1% Atropine (q12-24 hours) - Systemic NSAID - E-collar if needed - Re-evaluate in 5-7 days

4 9/2/15

Emergency Deep Ulcer

Diagnostic Tests - STT of contralateral eye - Fluorescein stain - +/- eye pressures

Emergency Deep Ulcer

Treatment

- Antimicrobials (q 2-6 hours) - Fluoroquinolones - +/- Cefazolin 5.55% - If lots of gram+ bacteria - Anti-proteolytics (q1 – 6 hours) - Serum - 1% EDTA - Pain control - 1% Atropine (q12-24 hours) - Systemic NSAID - Tramadol - E-collar if needed - Re-evaluate in 2-3 days

Emergency Glaucoma

Primary Glaucoma v Common Signalment § 3-9 year old Cocker Spaniel, Basset Hound, Mixed breed v Clinical signs § Acute redness, pain, corneal edema v Emergency treatment § Latanoprost Alternate every 5 minutes for § Dorzolamide+timolol 30-45 minutes § If no response • Aqueocentesis (27-30g needle) • Mannitol IV at 1-2 g/kg Must rule out an anterior lens v Prognosis luxation before giving latanoprost § guarded to poor

5 9/2/15

Emergency Glaucoma

Secondary Glaucoma Latanoprost contraindicated & will make anterior lens luxation worse v Most common etiologies § Anterior lens luxation • Terrier breeds § Anterior uveitis (many DDx) § Previous • Chronic low-grade uveitis v Clinical signs § Chronic (maybe “acute”) redness, pain, corneal edema v Emergency treatment § Treat underlying cause § Dorzolamide + timolol TID-QID v Prognosis § Poor à difficult to lower IOP

Emergency Anterior Lens Luxation

Diagnostic Tests Latanoprost contraindicated & will make anterior lens luxation worse v +/- STT v Fluorescein stain v Eye pressures Treatment v Trans-corneal reduction § If successful, give latanoprost q12 hrs for persistent v Surgical extraction § Required if manual reduction not successful

Emergency Anterior Lens Luxation

Trans-corneal reduction of an anterior lens luxation

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Not an emergency Buphthalmos

Clinical signs v Chronic v High IOP v Blind in affected eye v Enlarged globe v Lens subluxation § Aphakic crescent Treatment v Enucleation v Exenteration v Chemical cilary body ablation

Urgency Exophthalmos

Orbital Abscess Orbital Neoplasia v Acute and often painful v Chronic, slowly progressive, v Rapid response to therapy and typically non-painful v Often young age v Typically older age v Stick chewer ? v +/- decreased nasal air flow

Urgency Exophthalmos

Orbital Abscess

Orbital Abscess v Acute and painful v Rapid response to therapy v Treatment 2 weeks after therapy § Clavamox or Simplecef x 3-4 weeks § Systemic NSAID x 2-3 weeks § Lubrication if keratitis present

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Exophthalmos vs Buphthalmos

Prognostic indicators Overall prognosis v Caused by orbital mass v Caused by chronic glaucoma • Abscess, neoplasia, mucocele v Blind & lose light perception v Typically maintain vision v Typically normal or near- v Decreased retropulsion normal retropulsion v Globes are same size v Globes are different sizes

Exophthalmos Buphthalmos

Urgency Anterior Uveitis

“Classic” Clinical Signs Diagnostic Tests - Episcleral injection - Miosis - Corneal edema - Low IOP v +/- STT v Fluorescein stain v Eye pressures § Should be low • ≤ 7 mmHg in affected eye Uveitis photo • ≥ 5 mmHg between eyes § If high teens, developing secondary glaucoma v +/- systemic workup § Not necessary on emergency

Urgency Anterior Uveitis

“Classic” Clinical Signs Treatment - Episcleral injection - Miosis - Corneal edema - Low IOP v Topical steroids TID-QID § Neo/poly/dex 0.1% § Prednisolone acetate 1% v Atropine 1% q12-24 hours § Be cautious if IOP is in teens v Systemic NSAIDs § Corticosteroids not recommended due to potential of infectious or neoplastic disease v +/- topical NSAIDs

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Urgency Unilateral Hyphema

Diagnostic Tests v +/- STT v +/- fluorescein stain v Eye pressures § If high teens, developing secondary glaucoma v Systemic workup § Possibly rodenticide toxicity Differential Diagnoses v Coagulopathies v Anterior uveitis v Intraocular neoplasia v

Emergency Bilateral Hyphema

Diagnostic Tests v +/- STT v +/- fluorescein stain v Eye pressures § If high teens, developing secondary glaucoma v Systemic workup § Possibly rodenticide toxicity Differential Diagnoses v *** Coagulopathies *** v Anterior uveitis v Intraocular neoplasia v Retinal detachment

Urgency Acute Blindness

Diagnostic Approach v Assess Vision § Menace, maze test, cotton balls § Visual placing § Dazzle reflex • Cortical response v Ophthalmic exam § Opacity that impairs vision? § Normal fundus? § Normal PLRs? v Neurolocalization § PLRs are most helpful

9 9/2/15

Not really an SARDS emergency Sudden Acquired Retinal Degeneration Syndrome

Suggestive Findings v Bilateral blindness Normal Canine Fundus v History of: § Polyuria, polydipsia, polyphagia, weight gain v Dachshunds v Normal fundus v No neurologic disease

Diagnostic Tests v Electroretinogram § Normal = brain disease

Urgency Retinal Detachment

Marcus-Gunn Suggestive Findings v Lack of menace response v Marcus-Gunn pupil § Afferent denervation v § Affected eye = larger pupil v “Abnormal” fundus Diagnostic Tests v Blood pressure measurement § Should be >200 mmHg v Systemic workup § DDX: Systemic mycosis, toxoplasmosis, neoplasia, etc.

Urgency Retinal Detachment

Normal Feline Fundus Retinal Detachment

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Urgency Retinal Detachment

Exudative Retinal Detachment

Not an emergency Retinal Degeneration

Suggestive Findings v Blindness in different environment v Signalment § Inherited in Shih Tzu, Miniature , Labrador v Night blindness v +/- v +/- cataract formation v “Abnormal” fundus § Hyper-reflective § Small blood vessels Diagnostic Tests v Fundus evaluation

Urgency Optic Neuritis

Suggestive Findings v Unilateral or bilateral Optic Neuritis blindness v +/- neurologic disease v Myrdiasis & absent PLRs § may be minimally responsive to light v May have dazzle reflex v “Abnormal” fundus Diagnostic Tests v Electroretinogram (normal) v Systemic work up v MRI + CSF evaluation

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Urgency Ocular & Periocular Disease

Urgency Ocular & Periocular Trauma

Diagnostic Tests v +/- STT v Fluorescein stain v Tonometry v +/- skull radiographs v +/- CT Treatment v Topical antibiotics (ointment) v Systemic antibiotics v Systemic anti-inflammatories Prognosis v Good with no intraocular damage v Poor if hyphema present

Not an emergency Hypersensitivity Reactions

Diagnostic Tests v Good history v +/- STT v Fluorescein stain v +/- Tonometry

Treatment v Topical anti-inflammatories v Systemic anti-inflammatories § Dexamethasone SP à IV

Prognosis v Good to excellent

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Questions?

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