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Ophthalmic Emergency TipsGuidelines

By Todd Grant,2014-04-26 19:56
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Ophthalmic Emergency TipsGuidelines

    Ophthalmic Emergency Tips/Guidelines

    1. Corneal Foreign Body 2. Descemetocele

    3. Iris Prolapse

    4. Anterior Uveitis 5. Lens Luxation

    6. Glaucoma

    7. Herpetic Keratitis 8. Prices

    Corneal Foreign Body

    Corneal Foreign Bodies can be

    ; Adherent to the corneal surface

    ; Embedded in the superficial corneal tissue

    ; Embedded deep into the corneal tissue

    ; Full Penetration of the Cornea

    For those foreign bodies that are adherent to the corneal surface or superficial, removal can be attempted with care. Foreign bodies that are embedded deep or have penetrated the cornea, or if you are not sure if they are deep or penetrated, an ophthalmologist should be called to do removal.

    It is common for a secondary anterior uveitis to develop as a result of a corneal foreign body (reflex anterior uveitis), however if there is hyphema present, shallow anterior chamber or anterior synechia iris prolapse, it is likely that a full

    thickness penetration has occurred and an ophthalmologist should be called to do removal.

    If there are signs of infection or melting, the cornea should be treated as a complicated* corneal ulcer.

    If you are CONFIDENT that the foreign body is not deep nor has penetrated the anterior chamber, the following suggestions may be helpful:

    a. Apply topical proparacaine - recommend 1-2 drops every 1 minute for a total

    of 3 4 applications

    b. Patient must be sedated if not adequately still/restrained

    c. Attempt removal using a sterile cotton swab, Weck Cell Sponge,

    (cilia/jewelers/tying) forceps, or a 25- 30-gauge needle, or sharp irrigation (6

    cc syringe filled with sterile eye wash and fitted with 24 gauge IV catheter) if

    foreign body adhered to the corneal surface.

    d. If successful, best to stain eye with fluorescein and record corneal defect size

    and depth. TGH with: E-collar, Neopolybacitracin TID in dogs; Erythromycin

    TID in cats, atropine 1% BID, and systemic NSAID until recheck exam in 3

    5 days (hospitalize or recheck in 24 hours if the ulcer is complicated).

    Treatment in ES until referral or an in-house ophthalmologist is available. a. E-Collar

b. Ciprofloxacin Ophthalmic Solution: 1 drop every 2 hours

    c. Cefazolin Ophthalmic Solution (50 mg/ml): one drop every 2 hours (keep

    refrigerated) (when multiple eye drops are being used separate each by at

    least 10 minutes to avoid wash out). See Reference section. It is ok to just

    use ciprofloxacin drops if the pharmacy is not open.

    d. Atropine 1% solution one drop every 5 minutes for 3 doses (or to effect =

    pupil dilated), then two to three time per day.

    e. Systemic NSAID of your choice

    f. Systemic antibiotic (chose doxycycline if there is collagenase or melting since

    doxycycline is an excellent antiproteinase and gets into the tear film when

    given systemically). Choose other antibiotic systemically per your clinical

    judgment.

    g. Further systemic analgesia PRN

    h. DO NOT USE TOPICAL ANESTHETIC THERAPEUTICALLY

    PROPARACAINE WOULD DO HARM if used therapeutically!

    Descemetocele

    A Descemetocele is a surgical emergency. Needs a surgical graft. Diagnosis is made by observation. Do not stain with fluorescein if it appears that a Descemetocele is present since fluorescein stings and the rapid closure of the eye could rupture the cornea. Whether fluorescein would be retained or not is a moot point with a Descemetocele since this ulcer is too deep to expect to heal with only medical therapy. Do NOT use ointments.

Therapy prior to surgery

    1. E-collar

    2. Keep animal calm as possible even if this means drugs something with

    analgesia i.e.: low dose torbugesic or buprenorphine.

    3. Ciprofloxacin ophthalmic solution: 1 drop every 2 hours

    a. Cefazolin Ophthalmic Solution (50 mg/ml): one drop every 2 hours (keep

    refrigerated) (when multiple eye drops are being used separate each by at

    least 10 minutes to avoid wash out). See Reference section. It is ok to

    just use ciprofloxacin drops if the pharmacy is not open.

    4. Serum or plasma (EDTA) or EDTA: 1 drop every 2 hours

    5. Atropine 1% solution one drop every 5 minutes for 3 doses (or to effect = pupil

    dilated), then two to three time per day.

    6. Systemic NSAID of your choice

    7. Systemic antibiotic (chose doxycycline if there is collagenase or melting since

    doxycycline is an excellent antiproteinase and gets into the tear film when given

    systemically). Choose other antibiotic systemically per your clinical judgment.

    8. Further systemic analgesia PRN

    9. DO NOT USE TOPICAL ANESTHETIC THERAPEUTICALLY

    PROPARACAINE WOULD DO HARM if used therapeutically!

    Since this is a surgical disease, when Emergency submits the pre-anesthetic blood work, this will help the ophthalmologist a lot.

    Be sure to sedate the animal before taking blood or placing an IV catheter, since struggling during venapuncture or catheter placement could rupture the cornea from struggling.

    Iris Prolapse

    An iris prolapse is a surgical emergency and should not be stained with fluorescein. If the full thickness wound becomes unsealed/ruptures, the same therapy is used as for Descemetocele. Do not use ointments.

    Surgery must be arranged as soon as possible.

Therapy prior to surgery

    1. E-collar

    2. Keep animal calm as possible even if this means drugs something with

    analgesia i.e.: low dose torbugesic or buprenorphine.

    3. Ciprofloxacin ophthalmic solution: 1 drop every 2 hours

    a. Cefazolin Ophthalmic Solution (50 mg/ml): one drop every 2 hours (keep

    refrigerated) (when multiple eye drops are being used separate each by at

    least 10 minutes to avoid wash out). See Reference section. It is ok to

    just use ciprofloxacin drops if the pharmacy is not open.

     or plasma (EDTA) or EDTA: 1 drop every 2 hours 4. Serum

    5. Atropine 1% solution one drop every 5 minutes for 3 doses (or to effect = pupil

    dilated), then two to three time per day.

    6. Systemic NSAID of your choice

    7. Systemic antibiotic (chose doxycycline if there is collagenase or melting since

    doxycycline is an excellent antiproteinase and gets into the tear film when given

    systemically). Choose other antibiotic systemically per your clinical judgment.

    8. Further systemic analgesia PRN

    9. DO NOT USE TOPICAL ANESTHETIC THERAPEUTICALLY

    PROPARACAINE WOULD DO HARM if used therapeutically!

    Since this is a surgical disease, when Emergency submits the pre-anesthetic blood work, this will help the ophthalmologist a lot.

    Be sure to sedate the animal before taking blood or placing an IV catheter, since struggling during venapuncture or catheter placement could rupture the cornea from struggling.

    Anterior Uveitis

    Try to determine if Exogenous or Endogenous if possible.

    If exogenous (external blunt trauma) or Lens Induced Uveitis, or Pigmentary Uveitis of the Golden Retriever, Lens Induced Uveitis, etc., then a physical exam and basic laboratory work is all that is necessary (CBC, Chem Panel) just to be sure that the medical therapy is suited to the patient.

    The full diagnostic work-up must be offered if thought to be endogenous or if no obvious underlying cause; of course use clinical judgment based upon signalment, history, physical examination, geographic exposure and financial concerns (sort list based on above to put the most likely or important tests at the top):

    CAT DOG

    CBC CBC

    Chem Panel Chem Panel

    Chest X-Ray Chest X-Ray

    Snap 4 (Lyme, HW, E. canis, A. FeLV/FIV

    phagocytophyllum

    Bartonella WB Bartonella WB

    Lepto TOXO IgM IgG

    RMSF Save Extra Serum

    TOXO IgM IgG Crypotococcosis, Histoplasmosis pending

    PE, ocular exam and exposure potential.

    Babesia canis

    Brucella Plate Screening Test

    Neospora

    Save Extra Serum

    Deep Fungal Titers pending PE, fundic

    exam and Geographic Travel History

    Abdominal Ultrasound if PE indicates that Abdominal Ultrasound if PE indicates that

    this would be a valuable test. this would be a valuable test.

Therapy

    1. E-collar

    2. Prednisolone acetate 1% (dogs or cats) or Neopolydexamethasone (dogs): 1 drop

    QID*

    3. Flurbiprofen: 1 drop BID-see below

    4. Atropine 1%: 1 drop to effect to get pupil dilated (must consider resistance due to

    posterior synechia) and then BID**

    5. Starting doxycycline may be helpful for treatment of possible tick-borne disease until

    lab tests are back and to help control inflammation

    6. Consider starting clindamycin as well in cats

    7. Systemic NSAID (pending CBC and Chem Panel first)

    8. *Important to check for ulcers prior to topical steroid therapy. if present, use only

    flurbiprofen BID instead* Caution topical NSAIDs could lead to a worsening of ulcer

    or collagenase ulcer (melting). Therefore systemic NSAID is often sufficient if labs

    OK with only the use of a topical antimicrobial and atropine.

    *if patient is diabetic, topical steroids generally do not cause significant changes in

    glucose levels*

    9. **check IOP first and do not use atropine if elevated or if normal but higher than the

    normal eye [normal 12 26 mm Hg with no more than 6 8 mm Hg difference

    between the two eyes the uveitis eye should have a lower pressure than the

    normal eye in acute anterior uveitis!] If the Uveitis eye pressure is greater than 18

    20 mm Hg that could mean a compromise in aqueous outflow and frank glaucoma

    could occur with Atropine treatment, especially in a breed predisposed to glaucoma

    (Bassett Hound, Cocker Spaniel). The systemic NSAID may be sufficient for pain

    relief. Tropicamide has the same risks as atropine when the IOP is abnormally

    elevated or of a concern. In addition if the STT is low, consider the need for atropine

    since atropine will further decrease tear production. If atropine is necessary with low

    STT, be sure to add in extra ocular lubricants to protect the corneal surface from

    drying and exposure.

    Lens Luxation

    Lens luxations can be primary (inherited) or secondary.

    Primary Lens luxations occur in dogs and cats. The Terrier breed is over represented for primary lens Luxation as well as several dog breeds (see list in References section). Secondary lens Luxation occurs as the result of chronic uveitis weakening the lens zonules, lens resorption, buphthalmos causing stretching and breaking the lens zonules, and trauma. Lenses can be luxated anterior or posterior, the anterior lens luxation is the most dangerous in that it can suddenly block the aqueous flow through the pupil causing acute glaucoma.

    When there is acute glaucoma and generalized corneal edema, one often needs an index of suspicion that there is an anterior lens luxation. This is where knowing the breeds that are predisposed to lens luxation is helpful and if presented with such a breed and acute glaucoma; either an ocular ultrasound or giving IV mannitol would be the first step. Ocular ultrasound can localize the lens but sometimes it is not clear. IV mannitol will shrink the vitreous and thereby reduce intraocular volume, which will reduce intraocular pressure. When the pressure reduces the cornea will clear and the lens luxation can be see directly. If one were not to recognize that there is an anterior lens luxation and if Xalatan or Travatan were given the glaucoma would worsen since the pupil would become more miotic and further reduce aqueous flow since the lens is in the anterior chamber.

In the case of Anterior lens luxation this is a surgical situation however the

    intraocular pressure needs to be reduced first.

    A. If IOPs elevated* (> 30mmHg in small animals) IV Mannitol at 1-

    2 GRAMS/kg IV should be given slowly over 30 minutes. Use

    cautiously in patients with heart disease, kidney disease or patients

    that are dehydrated or hypovolemic.

    Be sure to stain for corneal ulceration and treat accordingly

    - superficial ulcer: TAB ointment TID-QID should suffice

    - deep ulcer:

    ; E-collar

    ; Ciprofloxacin: 1 drop q2 hours

    ; NO Atropine

    ; Serum: 1 drop q2 hours

    ; Systemic analgesia PRN

    ; Systemic NSAID or steroid (not both systemically)

    Steroid such as dexamethasone SP (0.1-0.2 mg/kg) is

    preferred since there is likely retinal and optic nerve

    damage from the acute pressure rise.

    ; Methazolamide: 2 5 mg/kg PO BID

    ; Cosopt: 1 drop TID

    The IOP should start to decrease in about 30 60 minutes.

    *Re-check IOPs over peripheral cornea, try to avoid going right over

    the lens

    ; Evaluate the "good" eye for sight, signs of lens luxation or

    subluxation, retinal exam (DO NOT dilate) and measure IOP. DO

    NOT DILATE THE PUPIL. If there is sign of posterior subluxation

    (deep anterior chamber, iridodenesis, aphakic crescent and the lens

    is behind the iris; consider starting on Xalatan once daily as well as

    a topical ophthalmic steroid such as Neopolydexamethasone or

    Prednisolone acetate. If the IOP is abnormally elevated the Xalatan

    should be enough however if there are no signs of lens luxation but

    the IOP is marginally elevated, start Cosopt TID. The mannitol and

    methazolamide as part of the therapy for the fellow eye above

    should markedly improve (reduce IOP) as well in the “good eye”.

    Clearly an ophthalmologist must remove the anterior luxated lens surgically as soon as possible. Your management as above is to try to keep the IOP in the normal range to preserve retinal and optic nerve function until the lens can be removed.

    At times, the lens will flip back to the vitreous at which point we can try a PGF2 (Xalatan or Travaprost/Travatan) to close the pupil and keep the lens posterior. If not already, in time the posterior subluxated or completely luxated lenses will develop a complete cataract and secondary LIU (lens induced uveitis). Treatment for the LIU is necessary. Removal of a posterior subluxated or completely luxated lens is not commonly recommended because of the high risk for retinal detachment; however there are select patients that would benefit from this surgery.

    Glaucoma

    The term glaucoma means abnormally high eye pressure.

    There is normal amount of pressure in the eye to maintain the normal health and function of the eye; however, if the eye pressure is abnormally elevated permanent damage to the eye can rapidly occur. The front internal portion of the eye contains a fluid called aqueous which brings in nutrition to the eye and carries out waste material from the eye. Aqueous fluid is constantly circulating in the front portion of the eye starting with the creation of aqueous behind the iris and then outflow through the pupil finally exiting the eye internally into the blood stream. The exit or outflow from the eye is through a sieve like structure called the “angle”. In the normal eye there is a balanced inflow and outflow of fluid, which results in the maintenance of normal eye pressure.

    Glaucoma always results from fluid not being able to escape from the eye through the pupil and / or angle.

    Glaucoma is a “clinical sign” and not a specific disease. There are many causes for glaucoma, all of which relate to obstruction of fluid outflow.

Causes of Glaucoma

    Causes for restriction of aqueous humor outflow can be due to an inherited defect in the angle, which can predispose the eyes to restricted outflow. There are certain breeds of animals that are over-represented for the development of glaucoma and within these breeds there are known anatomical angle abnormalities or weak lens ligaments, which could lead pupil block by a displaced lens. In addition there are situations where abnormal material in the aqueous, or swelling can obstruct the outflow as in hemorrhage, inflammation and scarring. Should these latter problems occur in an eye or eyes with an inherited angle defect, the likelihood of glaucoma developing is greater.

    Glaucoma is a “clinical sign” with many causes for abnormal elevation of IOP, here are some of the causes:

    1.Primary or Breed Associated

    2.Uveitis

    3.Trauma

    4.Lens Luxation

    5.Neoplasia

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