Red Eye

Question 1

describe glaucoma

Answer 1

1. diagnostic test: tonometry
   -but tonometry can be unreliable!
   -tonopen, tono-vet, shiotz
   -applanation and rebound tonometry: tonopen and tonovet, most accurate in vet med
   -5% variance reading considered accurate: is really just telling you how consistent you are
2. pipul size: mydriatic
3. pain is variable
4. other signs:
   -edema
   -buphthalmos
   -3rd eyelid elevated in “normal” eye because pain causes them to suck the eye back into their head
5. when you bring light closer to the eye, things get harder to see
   -so retroilluminate before direct illuminate

Question 2

describe orbital disease

Answer 2

1. diagnostic test:
   -retropulsion
   -if you think the eye is about to pop don’t push on it (also don’t squish a hole duh)
2. pupil size: normal
3. other signs:
   -difficulty opening mouth
   -elevated third eyelid
   -exposure ulcer
   -if inflammatory: pain
   -if cancer, may not be pain
   -exophthalmos
4. retrobulbar absces/cellulitis:
   -no bony floor to orbit so this is common!
   -soft tissue access to retrobulbar space behind last molar
   -very commonly: infected tooth root or something they chewed on went through and up into eye
   -present:
   -very painful, swollen, commonly young dog
   -mouth antibiotics: clindamycin, clavamox (anaerobes, “gross mouth shit”) plus treat inflam and pain and decrfease swelling
   -pred if young and healthy, carprofen if not
   -if was cellulitis, will be better in 5d; if comes back you missed something so then you can try advanced imaging or draining behind the eye, but is no longer emergency
5. if nonpainful geriatric, probably neoplasia
   -acute on chronic presentation, give them pain meds and send them home

Question 3

describe scleritis/episcleritis

Answer 3

1. diagnostic test: exclusion
2. pupil size: normal
3. +/- pain
4. other signs:
   -limbal redness
   -normal diagnostics
   -perilimbal edema
5. episcleritis:
   -nodular or redness at limbus
   -diagnosis of exclusion
   -response to topical steroid therapy is sufficient for diagnosis

Question 4

describe hyphema

Answer 4

1. diagnostic test:
   -examination
   -look for blunt trauma!
   -if cannot find trauma, next step is to check the blood pressure!
   -if BP and periocular exam are normal, now is a dog bleeding where it shouldn’t so treat like petechiae/ecchymosis and proceed from there
   -from ECC: make sure not bleeding out, put some steroid drops on there, and send out the door to see a regular doc to continue workup
   -so workup: BP, CBC (platelets), chem, coag panel, tick borne disease testing
2. pupil size:
   -normal to miotic
3. +/- pain
4. other signs:
   -hemorrhage elsewhere
   -low IOP
5. in cats is more likely to be associated with hypertension, especially geriatric cats
6. 8 ball hyphema
   -usually has bigger fish to fry

Question 5

describe uveitis

Answer 5

1. diagnostic test:
   -visualize flare
   -or other ways discussed after
   -just make sure they are not actively dying, stick some steroids in it, then send them somewhere less emergent for a workup
2. pupil size:
   -miotic
3. +/- pain
4. clincial signs:
   -red eye
   -small pupil!!
   -low IOP
   -corneal edema
   -keratic precipitates
   -secondary glaucoma

uvea is site of blood eye barrier, uveitis = barrier broken down

makes iris really sticky and more likely to scar down to the lens

Question 6

how best evaluate change in pupil size?

Answer 6

arms length away to get both pupils in image

Question 7

describe change in iris color

Answer 7

more likely to see if have a light colored iris

iris swelling, hyperemia, fibrin in anterior chamber
-lots of indicators that the eye is inflamed that don’t require you to spot flare

Question 8

describe aqueous flare

Answer 8

1. increased cells and protein in AH
   -hypopyon: pus/WBCs; doesn’t necessarily mean infection in the eye, just so much inflammation that the body is sending in cells to clean up
   –can be used to grade uveitis along with flare
   -hyphema: blood
   -fibrin
2. tyndall effect

Question 9

describe keratic precipitates

Answer 9

accumulations of inflammatory cells or fibrin adhering to corneal endothelium

Question 10

describe conjunctivitis

Answer 10

1. diagnostic test:
   -visualize follicles (enlarged look like fish eggs where eyelid and 3rd eyelid meet) or low STT
   -fast TFBUT
   -bilateral
2. normal pupil size
3. mild pain
4. other signs:
   -mucopurulent (purulent does not always mean bacteria, just means white cells) discharge
   -IOP/fl stain normal

NOT an emergency

5. dogs: allergic or dry eye, rarely infectious!
   -usually responds to topical antiinflam
   -always check for KCS
   -do not just start topical abx
6. cats: more commonly infectious contagious
   -more chemosis and hyperemia; could just need lubricant, abx case by case
   -self limiting in 2 weeks
   -if treating antibiotics, choose one the penetrates cells (ofloxacin, tetracyclines)
7. initial form/juvenile feline herpesvirus:
   -upper resp signs
   -secondary infections (neonatal infection)
   -can be self limiting
   -requires topical antibiotics +/- systemic abx
   -mild cases should resolve in 2 weeks

Question 11

describe KCS

Answer 11

1. clinical signs:
   -ropy mucopurulent discharge
   -conjunctival hyperemia, chemosis
   -keratitis with superficial neovascularization and pigmentation
2. ALWAYS STT
   -don’t send home steroids without doing STT they will ulcerate!!

Question 12

describe keratitis

Answer 12

1. ulcerative:
   -dx: fl stain
   -miotic pupils
   -painful
   -other signs: edema, vessels
   -need to determine: superfical (loss of epithelium but no stromal thickness) or deep (if deep will treat like it’s infected), infected or not, underlying conditions?
   -for an ulcer to get deep/if infected, the body is creating enzymes that are liquiefying the cornea to eliminate the infection and there is only 0.5mm room so infected can go from superficial to emergency overnight
   -abx and anti-inflam are dosed with your heart, the worse it looks the more you give since not worried abot systemic consequences
   -remember oral abx can only travel to cornea via blood supply (usualy not in cornea) so HAVE to treat topically sorry
   -when all stroma is gone: descmetocele, and rupture is imminent (start with drugs and send to referral if want to save eye or just take it out)
   -if already ruptured, do PLR and if other eye constrict there is potential for vision but surely need referral
2. non ulcerative:
   -dx: cytology, exam
   -normal pupil size
   - +/- pain
   -pigment, vessels, discharge, plaques

Question 13

describe non ulcerative keratitis

Answer 13

1. dx: cytology, exam
   -normal pupil size
   - +/- pain
   -pigment, vessels, discharge, plaques
2. auto immune keratitis
3. qualitative tear film abnormalities
4. corneal vessels, STT, IOP, and fl normal
   -may require cytology
5. often responds to steroid or cyclosporine
6. cats like to get eosinophilic plaques:
   -one eosiniophil on corneal scrape is diagnostic
7. dogs form is pannus:
   -chronic supercial keratitis
   -worsened by UV exposure: not as bad at sea level, much worse in colorado

Question 14

describe diagnosing red eye

Answer 14

1. menace, PLR (resting)
2. min opth database:
   -STT, fl stain, tonomtery
   -ALL should get unless you think the eye is going to pop
   -glaucoma, ulcers, and dry eye which all need specific therapy all will be diagnosed via this
   -the rest need some form of steroid
3. GOSHUCK:
   -glaucoma: dilated pupil, IOP to diagnose, usually unilateral
   -orbital disease: reduced retropulsion, check mouth
   -scleritis (episcleritis): rule out other causes, response to steroids
   -hyphema: fresh bleeds fill eye, old bleeds settle
   -uveitis: small pupil, flare, uni or bilateral