Ophtho Case Review: Corneal Ulcer
Happy Freaky Fr-EYE-Day!
Let me share with all of you my favorite Friday night emergency. The Boston Terrier with a corneal ulcer. 😜 (somewhere, many hundreds of miles away, an ophthalmologist feels the hair on the back of his or her neck stand up, and they don’t know why…).
This eye drives 3 hours to see me. I fix it. 💁🏻♀️ What about the eye that looks like this and won’t drive 15 minutes down the road to see one of us during the day?
Job 1- make the ulcer better.
Job 2- figure out why the ulcer happened.
Job 3- prevent this from happening again.
- Task 1- check tear production in both eyes. Over a period of 60 seconds. Full stop. Guess what my boston terrier had? DRY EYE.
- Task 2- check IOP in both eyes. (You can touch a corneal ulcer with a tonometer. This eye is not perforated. If you aren’t sure if there’s a perforation, don’t touch. Sometimes a glaucomatous eye makes an ulcer. That changes how you treat it!)
- Task 3- stain both eyes. You can see what picked up stain in this eye. Guess what the ‘good’ eye had? A teeny little ulcer. Guess why this boston was only sensitive in the eye you’re seeing a picture of? Because bostons have terrible corneal sensation. So do Shih tzus. And yorkies. And most of the things you will see with awful, infected corneal ulcers.
- Task 4- check for PLR (direct and consensual), menace response, dazzle reflex, palpebral response. (Don’t forget the normal stuff bc of how bad this looks.) What happens if this eye was blind? That’s going to change how heroically we try to save this, right? If there’s facial nerve paralysis, that changes how we approach this, how we treat this, the long term outlook, who you try to refer the dog to (maybe), etc. be ready with a plan.
- Task 5- while the eye is numb with proparacaine, use a sterile cotton swab or a cytobrush to make a cytology slide (cluster your whole sample on the slide in a spot the size of a dime - even a raging infection will only shed so much from the cornea), and collect an aerobic culture sample (just like you would from anywhere else on the body). When the eye is numb, do all of your touching then. If you have even one tech in your practice who reads ears or fecals, they can read this cytology for you. (But, so can you - you’re looking for bacteria, cocci or rods, and how much, streaming neutrophils or not.) no heat fixing, just clean diff quik.
Think practically. If there is dry eye, treat it. If there is facial nerve paralysis, treat it. Figure out the usual stuff first.
Submit your culture if you see bacteria. I personally recommend Colorado state university, as this is the *only* lab in the country that tests eye infections against ophthalmic medications (meaning they are not using oral medication disks to test their eye infection cultures). Super easy to send.
- Rigid e-collar.
- Broad spectrum topical antibiotic — in your practice, this should be neopolygram or neopolybac (no steroids!!!) AND usually a fluoroquinolone like Ciprofloxacin. Both q4-6hr.
- Autologous serum q2-4h to slow infection. (This needs to be stored in a sterile dropper bottle, otherwise, you are depositing bacteria into the wound. And, it’s good for 5 days in a fridge in a sterile bottle. You can collect more than that and send some home for the freezer, you can make aliquots from a donor dog or donor horse and freeze them to send home.)
- Terramycin q4h (to slow infection and speed healing)
- Doxycycline 5mg/kg po bid (or minocycline) to slow infection and speed healing - this penetrates the tear film.
- An oral NSAID (I like NOT galliprant in dogs — it doesn’t penetrate well intraocularly, and NOT Onsior in cats for the same reason, but this is VERY doctor dependent) — there is SO much reflex uveitis that is painful and vision threatening in some instances. An oral NSAID (or even steroid, if you prefer) is so helpful.
- Oral gabapentin for neuropathic pain control. (I am conservative when dosing geriatric patients, and I realize that this may not work immediately, but I personally feel that this helps with pain far better than tramadol in our eye patients.)
- If you live in fungus land, you may want to add topical itraconazole to start (most antifungals are compounded, and you should be able to see fungus on your cytology - by the way, if you see that, culture for fungus, also, but that will take a while to return).
At your practice, I would give atropine topically before they leave. I don’t generally dispense this to minimize what owners are already doing.
My surgical rule is 60% depth or greater has a surgical conversation. Some of these will still heal with medications. There are many factors that affect this.
At my practice — I use stem cell therapy (Vetrix), I sometimes use topical dilute betadine, I use dissolving collagen contact lenses. Some of us will use collagen cross-linking to slow infections. When we do operate, there are many variables — can we harvest autologous cornea for a graft? Can we use synthetic grafting materials or even amnion to prevent or minimize scarring? Is a conjunctival graft our only option?
***every ophthalmologist is different. We will all treat slightly differently, treat each case slightly differently (bc each animal is different, and each owner is different), and we will advise each one of you slightly differently. But we all have the same idea in mind. You can see that the three of us VetHive Ophtho Guides all do things just a teeny bit differently, but mostly the same. What I described as a generic plan to you above was not my exact plan for this poor Boston. It is just a starting place for your next freaky freyeday nightmare of your own. ;)
Infected ulcers should NOT be treated with third eyelid flaps. There is no amount of serum that a third eyelid flap will deliver that will heal a malacic ulcer, and you can do better with any of the medications I listed above. A third eyelid flap will hide this ulcer from you and create a warm, dark environment for more growth. Third eyelid flaps in THIS circumstance are considered malpractice. 😢
Make an owner a checklist for medications if you can. Explain that the number of doses is ultimately more important than the hours inbetween (people have to work, and they will skip the fourth dose — humans rarely give themselves TID medicines. So imagine.). Recheck in 2-3 days for better or worse. Keep trying to refer.
Check in with an ophthalmologist you like and trust for help. You are never alone.
My favorite thing to tell owners is that during healing, “the redder, the better.” That means that the redder the surface of the eye gets, the better it is! We can get rid of redness after healing is done. Redness doesn’t hurt. Redness is the animal trying to heal itself. (Redness on the eye is terrifying if an owner doesn’t know what it is!)
Remember — everything looks terrifying about an eye! Start with what you know, and phone, or VetHive message, some friends. 🐝❤️👁️
About the Guide: Elizabeth A. Lutz, DVM, MS, DACVO (Ophthalmology)
Dr. Elizabeth Lutz received her Bachelor of Arts degree from the University of Pennsylvania, and her Doctorate of Veterinary Medicine from Cornell University. She completed a rotating internship in small animal medicine and surgery followed by a specialty internship in ophthalmology at Long Island Veterinary Specialists. Dr. Lutz finished a research fellowship in comparative ophthalmology followed by her Residency in Comparative Ophthalmology at The Ohio State University, and holds a Master of Science in Comparative Veterinary Medicine from The Ohio State University, with an emphasis in Comparative Ophthalmology. Dr. Lutz achieved board-certification in veterinary ophthalmology through the ACVO. Her clinical interests are diverse, and include the medical and surgical management of glaucoma, lens surgery, corneal surgery, the novel treatment of tear film diseases, exotic animal ophthalmology, and equine ophthalmology.
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