Feline Ophthalmology - APVCapvc.ca/notes/2019notes/Wilkie6-vet.pdf · 2/12/19 1 Feline...
Transcript of Feline Ophthalmology - APVCapvc.ca/notes/2019notes/Wilkie6-vet.pdf · 2/12/19 1 Feline...
2/12/19
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Feline Ophthalmology
David A. Wilkie DVM, MS, DiplomateACVO
Professor EmeritusThe Ohio State University
Agenesisn lack of development
of the upper eyelidn superior-temporal
50% of the eyelidn usually bilateral
Dziezyc/Millichamp modification
What is wrong with this image?
What the books tell you to do
Dziezyc/Millichamp modification
What is wrong with this image?
What the books tell you to do
Hair grows towards the cornea!!
Lip to Lid
From: Popesko P: Atlas of topographical anatomy of the domestic animals
Parotid duct
Facial v.Facial n. dorsal and ventral buccal branch
Orbicularis oris
Bucinnator
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Lip to Lid
Whittaker CJG, Wilkie DA, et al: Lip commissure to eyelidtransposition for repair of feline eyelid agenesis. Vet Ophth 13:173-178, 2010
Parotid Duct
Oral Mucosa
Bridge incision
Bridge incision
Conjunctiva to oral mucosa8-0 vicryl simple continuous
Immediately Post-op
Immediately Post-op
2 months Post-op Symblepharon
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AnkyloblepharonSymblepharon
Preop-9 months old-has not seen since birth
Ankyloblepharon/Symblepharon
Preop
Postop
EntropionOften acquired, secondary to corneal disease
Permanent Lateral Tarrsoraphy
Modified Hotz-Celsus
A combined HC and lateral canthal closure had a 99.21% success rate of resolving lower lid entropion
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Eyelid Neoplasia
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Feline Eyelid Neoplasia
SCC SCC
Mast Cell Fibrosarcoma
Mast CellTumor Peripheral Nerve Sheath Tumor
Coplow
Mast Cell Tumor
ResultsAll periocular CMCTs were restricted to the eyelids. In addition to surgical excision, three cats were treated with adjunctive therapy (strontium-90 irradiation or cryotherapy) intraoperatively. Local tumor control was achieved in 22/23 cats with a minimum follow-up of 30 days (median follow-up time of 711 days); one cat developed disseminated CMCTs but no local recurrence. Cats with periocular CMCTs had a median survival time of 945 days. Metastatic disease involving peripheral lymph nodes or abdominal viscera was not detected in any cat at any time during the study. All periocularCMCTs were classified as low-grade based on histopathology, and complete excision was achieved in approximately 50% of cases.
Conclusions Surgical excision of periocular CMCTs in cats is an effective treatment option with rare local recurrence and metastases, even following incomplete surgical
excision.
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Feline conjunctival melanoma Feline conjunctival melanomaConjunctival Melanoma- 55% mortality
Eyelid Neoplasian Treatment:
n Dog vs. Catn Benign neglectn Surgery
n Excisional biopsyn Cryosurgeryn CO2 laser
n Chemotherapyn Radiation
1/3<1/3 <1/3
How much can I remove?
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n Reconstruction of larger eyelid mass excisionsn H-plasty/Z-plastyn Semicircular flapn Split eyelid flapn Cross eyelid flapn Rhomboid graft flapn Lip to Lidn Axial pattern flap
n H-Plastyn Repair of larger
excisionsn Preserve as much
conjunctiva as possible
n Diverging incisions
From: Projects by Dittmann J: http://www.delta-3.de/
ab
b = 120% a
Z-Plasty-for lateral canthus
From: Projects by Dittmann J: http://www.delta-3.de/
Feline Mast Cell Tumor
Z-Plasty Z-Plasty
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Post-op
Suture Removal
Feline SCC Axial Pattern Flap
5 days post cryo for conjunctival/eyelid hemangiosarcoma
Infectious Feline Conjunctivitis
n Clinical Signsn epiphora - usually
serousn blepharospasmn chemosisn conjunctival
hyperemia
Infectious Feline Conjunctivitis
n Clinical Signsn epiphora - usually
serousn blepharospasmn chemosisn conjunctival
hyperemian +/- Corneal
ulceration
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Infectious Feline Conjunctivitis
n Etiologyn Herpes felisn Chlamydophila felisn Calicivirus
Chlamydophila felisconjunctivitis
n Diagnosisn clinical signsn presence of
elementary bodies in the conjunctival epithelial cells
Chlamydophila felisconjunctivitis
n Potential zoonosis
Chlamydophila felisconjunctivitis
n Treatmentn Antibiotics
n Tetracyclinen 4x/day OU
n Erythromycin/Macrolides
n wash hands
Herpes felisn 3 syndromes in the cat based on the
age of the patient:n Ophthalmia neonatorum - <4 weeks
oldn Adolescent catn Adult cat
Ophthalmia neonatorum n purulent discharge, usually bilateraln corneal ulceration - severen upper respiratory infection oftenn Secondary bacterial opportunistsn �Barn cat Syndrome�
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Symblepharon
Adolescent cat -herpes n ulcerative keratitis, conjunctivitisn upper respiratory infectionn uni- or bilateral
Adult cat - herpesn classic dendritic
ulcern no URT signs
Herpesn Diagnosis
n dendritic or punctate superficial corneal ulcersn pathognomonic
for herpes keratitis
Herpes felisn 70% of cats infected with herpes virus
will become carriersn recurrent conjunctivitis/keratitisn stress and immunosuppression will
predispose to recurrencen FeLVn FIVn Other
Herpes felisn Diagnosis:
n History - previous stress?
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Herpes felisn Treatment:
n Antiviral agents topicallynIdoxuridine - Stoxil, HerplexnTrifluorothymidine - Viropticnq2-4 hr
n Cidofovir 0.5%nQ12 hr
Herpes felisn Treatment
n Antivirals - Systemicn Famciclovir
n Variable doses listedn 65 mg/cat divided dailyn New data suggests 40 mg/kg POn 90 mg/kg PO TID
Herpes felisn Treatment:
n L-lysine, 250-500 mg/day PO
Acute Eruptive Keratopathy
Possible association with systemicImmunosuppression
PrednisoneCyclosporin
Acute Eruptive Bullous Keratopathy
Descemet’s membrane rupture
Acute Eruptive Bullous Keratopathy4 hr preop
1 hr preop
4 wk Post-op
4 wk Post-op
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Acute Eruptive Keratopathy
Treatment with conjunctivalgraft or 3rd eyelid flap
Eosinophilic Keratitis
Eosinophilic keratitis n Diagnosis:
n Cytologyn Mast cellsn Eosinophils
Eosinophilic keratitis
Eosinophilic keratitis n Treatment:
n Topical cyclosporine
Eosinophilic keratitis n Treatment:
n Topical corticosteroidsn4-6x/day for 7 days nThen taper to control
n Note the risk for Herpes
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Pre treatment
7 days Post treatment with 0.1% dexamethasone
Eosinophilic Keratitis n Treatment
n Ovaban® n 5mg/cat SID for 4-7 daysn taper the dose to a maintenance level of 1.25 -
2.5mg/cat/weekn side effects:
n weight gainn mammary gland hyperplasia and neoplasian diabetes mellitusn behavior changes
n Topicaln 0.5% compounded
n BID-TID
n Stiles: ACVO 2015
Corneal Sequestrationn Clinical signs
n Brown-black corneal lesion
n Painful, often vascularized, fluorescein negative
n Associated with Herpes keratitis
n Can cause with:n Topical steroidsn Grid keratotomy
Corneal Sequestrationn Risk factors
n Brachycephalic catn Chronic irritationn Herpes
SequestrumMay spontaneously slough
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Corneal Sequestration n Treatment
n Superficial keratectomy
Sequestrum
Preop
Postop
Corneal Sequestration n Treatment
n Superficial keratectomy
n Conjunctival graftn Amnionn Corneal graft
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Corneal Ulcer
n Do cats get indolent ulcers?n Yes
Corneal Ulcern Do cats get indolent ulcers?
n Yesn Can I do a debridement and a grid
keratotomy?n NO!
Diamond Burr Debridement
Courtesy Dr Enry Garcia, University of Colorado
Jury still out on cats
Feline UveitisAnterior Uveitis
n Etiologiesn The etiologies of anterior uveitis can
be either ocular or systemic.
OcularSystemic
Uveitis
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Anterior Uveitisn Ocular Etiologies
n There are only 4 main ocular causes, rule them out first
Anterior Uveitisn Ocular:
n Corneal ulceration
n Lens-inducedn Ocular trauman Neoplasia
n primary
Anterior Uveitisn Systemic Etiologies:
n Bacteremia, viremia, or septicemian Autoimmunen Metastatic neoplasian A complete physical examination is
therefore essential.
Feline Uveitisn Davidson MG, Nasisse MP, et al. Feline Anterior
Uveitis: A study of 53 cases. J Am An Hosp Assoc1991;27:77-83
n Lappin MR, Marks A, et al. Serologic prevalence of selected infectious diseases in cats with uveitis. JAVMA 1992;201:1005-1016
n Peiffer RL, Wilcock BP, et al. Histopathologic study of uveitis in cats: 139 cases (1978-1988). JAVMA 1991;198:135-138
Feline Uveitisn Mean Age - 8.6 yrsn 2.6 : 1 male to femalen Most breeds w/ DSH or DLH
predominate
Feline Uveitisn Idiopathic / Immune-mediated
n (58% MGD; 33%RLP)n Neoplasia
n (13% MGD; 23% RLP)n Systemic infectious disease
n (26% MGD; 24.5% RLP; 83.1% MRL)
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Feline Infectious Disease• FELV (12%)• FIP (5-19%)• Toxo (5-75%)• FIV (13-21%)• Crypto (2%)• Bartonella
Cat may have more than one of these
Crypto
Crypto Crypto
Dr. Mike Davidson
FeLV FIV - Retinal dysplasia
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Toxo FIP
Dr. Mike Davidson
FIP FIP
FIP Histoplasmosis
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What is this? What would you do? Blastomycosis6 days later
Incidence of Bartonella Infection in US Cats
20% OVERALL
Regions: 1.2.3.4.
17%9%
28%22%
States with the highest incidence of infectionStates with moderately high incidence of infectionStates with moderate incidence of infectionStates with low incidence of infection
Incidence of Bartonella infection in cats increases in hot and humid climates because fleas flourish in these conditions.
Jameson, et al. J Inf Dis 172: 1145-9, 1995. CDC
20% OVERALL
Pre-treatment
Post-treatment
Bartonella +
Bartonella -Anterior Uveitis OU
n DSH, 7 months oldn Negative for: FIV, FeLV, toxoplasmosis, and FIP
Anterior Uveitisn Diagnostic Tests
n History - Duration, progression of diseasen Physical examination n Complete blood countn WBC count, Differentialn Platlet count
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Anterior Uveitisn Diagnostic Tests
n Biochemical profilen Serology
n FeLV, FIV, Toxo, Bartonella, Fungal
n Radiologyn Ultrasoundn Cytology/Histopathology
Ocular Oncology
Primary - intraocular Secondary - intraocular
Melanoma LymphosarcomaAdenoma/Adenocarcinoma CarcinomaSpindle cell sarcoma - cat Sarcoma
Primary or Secondary? Feline Neoplastic Uveitisn Lymphosarcoma #1
Feline Neoplastic Uveitisn Uveal melanoma
Enucleate
MonitorMonitor
Neoplasian Primary
n Melanoman anterior uvea (iris & ciliary body).n Incidence of metastasis may be as high as 60%n mitotic index for the tumor
n exceeds 10/HPF - malignant
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Progression over 4 years
- significance?-what would you
recommend?
Feline Iris Melanoma -suspected
Differential diagnosisuveal cysts
Neoplasian Primary
n Feline Spindle Cell Sarcoma (post-traumatic sarcoma)
Traumatic laceration- 4yr previously
Neoplasian Primary
n Feline Spindle Cell Sarcoma (post-traumatic sarcoma)n Arise from lens epithelial cells?? n Raren Induced by intraocular gentocin?n Highly malignant
n Metastasize n invade along the optic nerve to the
CNSn All blind feline eyes with evidence of
prior trauma or inflammation should be considered for enucleation
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Feline post-traumatic sarcoma Glaucoman Glaucoma in the cat is
rare compared to the dog
n Most cases of feline glaucoma are secondary in nature (87%)-uveitis-neoplasia
Glaucoman Clinical signs
n Subtle compared with canine
n The cat, generally does not exhibit pain, redness, or diffuse corneal edema
Primary Glaucoma n Although rare, I do believe that primary
open-angle glaucoma occurs in the Siamese catn European shorthairn Burmese
Glaucoman Be cautious with topical alpha-2
agonistsn Likely should avoid!n Sedation, cardiovascularn Death?
Secondary Glaucoman Etiologies
n Synechian Uveitis
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Uveal Cysts and Glaucoma
Uveal Cysts and Glaucoma
Diode laser ablation
Optic Nerven Excessive
myelinationn Aged cat
Enrofloxacinn Acute Blindness in Catsn Occurs at therapeutic dosen Irreversible
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Enrofloxacin 50mg/kgRetinal Detachment
n Etiologiesn Inflammationn Trauman Hypertensionn Infectious
Hypertension
Feline Hypertensive Retinopathy Feline Hypertensive Retinopathy
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Feline Hypertensive Retinopathy
Hypertensionn Treatment
nAmlodipinen Cat ¼ to ½ of a 2.5 mg tablet (0.625 to 1.25 mg)
given once or twice dailyn Dog 0.1 to 0.4 mg/kg PO, given once or twice daily
nEnalapriln Cat 0.25 to 0.5 mg/kg PO once or daily n Dog 0.5 to 1 mg/kg PO q12h