3/28/16. You can always take the eye out later!

Transcription

1 Proptosis Eyelid Lacera7on Corneal Lacera7on Descemetocele Corneal Rupture Lens Capsule Rupture Acute Glaucoma Anterior Lens Luxa7on Gunshot Wound Foreign Body Sudden, forward displacement of globe with entrapment of eyelids behind equator Usually the result of trauma Brachycephalics require minimal trauma to cause a proptosis Dolichocephalics require much more trauma to cause a proptosis 20% of dogs will regain vision azer replacement of globe You can always take the eye out later! Most owners would prefer to have a two-eyed dog where one eye is blind, than a one-eyed dog Medial rectus is typically the first muscle avulsed If more than two extraocular rectus muscles are avulsed, the globe should be removed 1

2 Hyphema ozen indicates scleral tear Proptosis pa7ents frequently develop KCS, which can result in long term treatment Must be placed under anesthesia ASAP Keep eye lubricated un7l anesthesia Replace globe (perform a lateral canthotomy if you can t get the globe back in the correct place) Use 2-0 to 4-0 nonabsorbable suture with stents and two horizontal mafress sutures Only treat the eye topically if there is corneal ulcera7on Carprofen BID for 1 week Tramadol TID for 1 week Remove sutures and stents in 2 weeks Long-term sequela Blindness Strabismus Exophthalmos Lagophthalmos KCS Kera77s Phthisis bulbi Glaucoma Trauma7c in nature (dog fight, foreign body tear) Surgical repair is necessary to maintain eyelid func7on, ocular health, cosmesis 2

3 General anesthesia is necessary for proper repair Magnifica7on is necessary for proper alignment and suture manipula7on Excise minimal, if any 7ssue 6-0 Vicryl as a subcutaneous suture (simple con7nuous) Use 6-0 Prolene as skin sutures Figure of 8 suture at eyelid margin Simple interrupteds tying previous suture ends away from the cornea Carprofen BID for 1 week Tramadol TID for 1 week Cephalexin BID for 2 weeks E-Collar at all 7mes Suture removal in two weeks Frequently seen in dogs (especially dogs less than 2-3 years old) who have met a cat for the first 7me Acute pain and you may see iris protruding through cornea Lacera7on may involve lens capsule This leads to cataract, lens induced uvei7s, poten7al glaucoma Phacoemulsifica7on may be necessary 3

4 Post-op poten7al for intraocular bacterial contamina7on, persistent uvei7s, glaucoma, re7nal detachment Post-Op E-Collar for 2 weeks Ofloxacin QID for 2 weeks Atropine SID for 1 week Oral carprofen for 2 weeks Oral Clavamox for 2 weeks Descemetocele Penetrates through the epithelium and the stroma to reach Descemet s membrane Most have bacterial involvement or calcific degenera7on Extreme risk of corneal rupture Surgical grazing is required Medical management frequently fails and results in corneal rupture Surgery is required for successful outcome Conjunc7val Pedicle GraZ (CPG) A-cell GraZing Corneal Conjunc7val Transposi7on (CCT) 4

5 Full thickness corneal penetra7on Frequently involve Iris prolapse Fibrin plug Hyphema Aqueous leakage Important Considera7ons Does the pa7ent have a menace response? Does the pa7ent have a dazzle response? Does the pa7ent have a consensual pupillary light response? If the pa7ent does not have a consensual PLR or a dazzle response, vision is not likely salvageable through grazing techniques Surgical Op7ons: Corneal Conjunc7val Transposi7on A-Cell GraZ Conjunc7val Pedicle GraZ Corneal Transplanta7on Enuclea7on Conjunc7val Pedicle GraZs 5

6 Pros U7lizes pa7ent s own 7ssue Minimal inflammatory response Adds strength to the cornea Adds ac7ve vasculariza7on Cons Adds blind spot Large corneal scar Magnifica7on and surgical exper7se necessary Corneal Conjunc7val Transposi7on Pros U7lizes pa7ent s own 7ssue Minimal inflammatory response (although larger than a conjunc7val pedicle graz) Adds strength to the cornea Adds ac7ve vasculariza7on Clear visual axis post-op Cons Adds blind spot Large corneal scar (not as large as a conjunc7val graz) Magnifica7on and surgical exper7se necessary (more so than a conjunc7val pedicle graz) A-Cell/Biosis Corneal GraZing 6

7 Pros Minimal corneal scarring Adds strength to the cornea More comfortable post-opera7vely Cons Magnifica7on and surgical exper7se necessary Easier to re-rupture Extremely inflammatory post-op Commonly seen in diabe7cs and rapidly progressive cataracts Affected dogs were diabe7c an average of 123 days and had cataracts for 39 days (Wilkie et al., 2002, 2006) Diabe7cs have a significant osmo7c component that results in rapid intumescence of the lens Most ruptures occur equatorially (>95%) Rapid referral of diabe7cs and surgical interven7on is key Aggressive an7-inflammatory treatment is key Topical prednisolone acetate or topical dexamethasone QID Topical flurbiprofen or diclofenac QID Oral carprofen BID Very high risk of re7nal detachment, glaucoma, poten7al loss of the eye Extremely important to inform clients of this 7

8 Glaucoma is an increase in the IOP to a level that is incompa7ble with the health of the eye Glaucoma is the single most common cause of blindness in dogs Always the result of a decrease in ouqlow Normal Intraocular Pressure for a dog is 15-25mmHg is a good normal range Glaucoma pressures will be >25-30mmHg Aqueous Flow Ciliary Epithelium Between Iris and Lens Through Pupil Iridocorneal Angle Pectinate Ligaments Trabecular Meshwork Blood Venous System Not associated with any other ocular disease Generally seen in predisposed breeds 50% will present bilateral within 2 years Check IOP every 3-4 months Preven7ve therapy for good eye (Dorzolamide BID) 8

9 Corneal Edema Dilated Pupil/ Sluggish PLR Decreased or absent menace Pain Episcleral Injec7on Mannitol Given IV gm/kg (over 15-20min Withhold water 3-4 hours 20-30min onset; 4-6 hour dura7on Dehydrates vitreous Avoid in pa7ents with dehydra7on, CHF, subdural hemorrhage If acute, primary glaucoma, and there is not an anterior lens luxa7on Give latanoprost and dorzolamide, alterna7ng, every 5 minutes for minutes and then recheck intraocular pressure No studies suppor7ng this at this 7me Con7nue with dorzolamide TID and latanoprost BID and recheck in 1 week Forward displacement of the crystallin lens Minimal anterior chamber depth Commonly causes a rapid rise in intraocular pressure causing permanent blindness 9

10 Subclinical uvei7s due to lens bumping into other intraocular structures Focal corneal edema due to kiss lesions from the lens Primary Lens Luxa7on occurs: Jack Russell Terrier Sealyham Terrier Wire-haired Fox Terrier Miniature Bull Terrier Tibetan Terrier Shar Pei Border Collie German Shepherd Various Spaniels Chihuahuas? Anything from AirsoZ pellets to gunshot pellets, to paintballs Largely depends on the level of damage done to the eye Superficial? Corneal Penetra7on? Hyphema? Courtesy Maf Fife 8 year old dog accidentally shot by an AirsoZ gun on Christmas Moderately painful Superficial corneal ulcer was found Treated with ofloxacin QID and oral carprofen for 1 week Recheck in 1 week showed that the ulcer was healed with a small scar 10

11 Roscoe, 4 year old, male neutered, German Shorthair Pointer Accidentally shot during bird hun7ng Roscoe was ini7ally ultrasounded and found to have a detached re7na His owner knew he would never regain vision, and that glaucoma was a significant risk, but wanted to keep the eye Treated with 2 weeks of oral carprofen, tramadol, and clavamox Tapering dosages of topical flurbiprofen and dexamethasone star7ng at QID and tapered every 2-3 weeks Owner very happy and Roscoe is comfortable Abby, a 6 year old, female spayed, Golden Retriever, went out to use the restroom first thing in the morning Owner has a heavily wooded lot She was a lifle surprised at how Abby came back in to the house 11

12 Abby was excep7onally happy on presenta7on CT scan was offered and performed to determine the extent of the injury CT showed ventral displacement of the globe 3D reconstruc7on was performed (for fun really) Taken to surgery and globe was manually held in place with a muscle hook S7ck was slowly extracted Large hole in dorsal conjunc7va was seen and irrigated profusely Minimal blood was seen post-op Completely visual with no problems Concern for poten7al remaining foreign bodies or organisms (splinters, bacteria, fungi) Post-op medicated with 2 weeks of carprofen, tramadol, clavamox 12

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