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Ophthalmological emergencies

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Abstract

Ocular emergencies can be intimidating and frustrating for veterinary surgeons (veterinarians). Many ophthalmological emergencies can be diagnosed and treated successfully with the basic equipment available to every veterinary surgeon. This chapter discusses the diagnosis, treatment and prognosis of common ophthalmological emergencies.

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Figures

Image of 10.1
10.1 (a) Proptosis of the left globe in a French Bulldog puppy. There is entrapment of the eyelids as well as severe swelling and hyperaemia of the bulbar conjunctiva. Note no extraocular muscles have been torn. On examination, the patient had positive direct and indirect PLRs of the left eye. The eye was replaced and a temporary tarsorraphy was performed. (b) Severe proptosis of the left globe (lateral view) with avulsion of several extraocular muscles in a cross-breed dog. In spite of the clear and intact anterior segment, the eye was enucleated because of the poor prognosis. (a, Courtesy H Appelboam; b, Courtesy of N Escanilla)
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10.2 Temporary tarsorrhapy. The lid fissure is closed by two or three U-shaped sutures. Rubber pieces, for example infusion or butterfly catheter tubing, are used to prevent the suture from cutting into the skin. All sutures should be preplaced before tying. The margins of the upper and lower lid should be perfectly apposed in order to avoid a rubbing effect of the sutures on the cornea. A small space should be left open medially to allow placement of medications. If previously performed, the lateral canthotomy can be closed by a figure-of-eight suture at the lid margin and further simple interrupted sutures. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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10.3 (a) A lateral canthotomy is performed. (b) The globe is dissected free from the conjunctiva and Tenon’s capsule through a bulbar conjunctival incision made approximately 5 mm posterior to the limbus. (c) The extraocular muscle insertions are dissected from the globe and the optic nerve is transected. There is no need to clamp the optic nerve with haemostatic forceps prior to transecting it. Traction on the optic nerve must be avoided in order not to damage contralateral optic nerve fibres at the crossover point in the optic chiasm. (d) The cavity is packed with gauze sponges for temporary haemostasis, and the nictitating membrane and all remaining conjunctiva are completely removed. (e) A 3–5 mm section of the eyelid margin is removed with scissors. (f) The gauze sponges are removed and the orbital fascia and periorbita are sutured with 1.5 metric (4/0 USP) absorbable suture material in a simple continuous or interrupted pattern. Some ophthalmologists implant an appropriately sized silicon prosthesis in the orbit prior to closing the orbital fascia and periorbita. (g) The skin is closed with simple interrupted sutures using 1.0 or 1.5 metric (5/0 or 4/0 USP) non-absorbable monofilament suture material (e.g. nylon). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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10.4 (a) Full-thickness marginal eyelid laceration in a 2-month-old Domestic Shorthair kitten. (b) Postoperative appearance of the same eye. The wound margins were minimally debrided and sutured in two layers as described in Figure 10.5 . The ends of all skin sutures are left long and tucked under the subsequent suture to ensure they are directed away from the cornea.
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10.5 Suturing a full-thickness marginal laceration. (a) The subcutaneous tissue is sutured using an absorbable 0.7–1.0 metric (6/0–5/0 USP) suture material (e.g. poliglecaprone 25, polyglactin 910). The lid margin and the angles of the wound are sutured first, followed by the remaining subcutaneous tissue. (b) The skin is closed with simple interrupted non-absorbable 0.7–1.0 metric (6/0–5/0 USP) monofilament sutures (e.g. nylon). The free lid margin should be apposed very precisely with a figure-of-eight suture. The angles of the wound are sutured afterwards, and then the remaining wound. (c) The ends of skin sutures that are close to the lid margin are left long and tucked under the subsequent suture to ensure they are directed away from the cornea. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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10.7 Severe herpesvirus keratoconjunctivitis in a 2-month-old kitten. Note the purulent discharge, conjunctival hyperaemia, diffuse corneal oedema and corneal ulceration. The nictitating membrane is elevated and immovable due to symblepharon.
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10.8 (a) Ophthalmia neonatorum with pus extruding from the medial canthus in a 7-day-puppy. (b) Note the characteristic distended appearance of the eyelids of the left eye.
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10.10 Schirmer tear test.
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10.11 (a) Superficial corneal ulcer in a dog caused by a chemical burn with an alkaline agent (caustic soda). Note the severe corneal oedema limited to the ulcerative area, the conjunctival hyperaemia, and the burn lesions on the eyelid margins. The eye was copiously irrigated with sterile lactated Ringer´s solution and was treated topically with one drop of atropine, ofloxacin q6h, oxytetracycline (anticollagenase) q6h and an oral NSAID q24h. The ulcer was completely healed 1 week later. (b) The same eye 1 month later.
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10.12 (a) Deep corneal ulcer in a Shih Tzu caused by an ectopic cilium on the upper lid. (b) Two ectopic cilia can be observed on the upper lid (arrow and arrowhead); the ulcer was caused by the ectopic cilium located in the centre (arrowed).
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10.13 (a) Melting corneal ulcer in a dog. The ulcer was deep, affecting more than two-thirds of the corneal thickness, and thus a combination of surgical and medical treatments was performed. (b) The eye 1 month after placement of a pedicle conjunctival graft.
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10.14 Melting corneal ulcer in a cat.
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10.15 Central corneal descemetocele in a dog with keratoconjunctivitis sicca and distichiasis. Note the fluorescein uptake in the periphery of the ulcer. The base (Descemet’s membrane) does not take up the stain.
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10.16 (a) Corneal perforation in a Pekingese. Note the small iris prolapse at the centre of the corneal lesion (arrowed). (b) The eye 6 weeks after surgical replacement of the iris into the anterior chamber followed by a corneoconjunctival transposition.
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10.17 Full-thickness corneal laceration in a dog resulting from a cat claw injury. Note the corneal oedema around the edges and a fibrin clot sealing the full-thickness defect (arrowed).
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10.18 (a) Superficial partially embedded corneal foreign body. Note the conjunctival hyperaemia and perilesional corneal oedema surrounding the foreign body (arrowed). This was a piece of plant material that was gently removed using a 25 G needle. (b) The eye following removal of the foreign body. (Courtesy of C Peruccio)
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10.21 Acute primary glaucoma (narrow angle) in an English Cocker Spaniel. Note the redness (due to conjunctival hyperaemia and episcleral congestion), diffuse corneal oedema and mydriasis. The intraocular pressure is 64 mmHg.
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10.22 Tonometry is the measurement of IOP. The most frequently used techniques include applanation and rebound tonometry. For accurate readings and in order to avoid erroneous overestimations of IOP, the animal should be resting quietly and the eye lids should be opened from over the bony orbital rim thereby avoiding pressure on the globe. The IOP should be measured in both eyes.
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10.23 Acute anterior uveitis in a dog with lymphoma. The visible haziness in this eye is caused by slight corneal oedema and aqueous flare. Note the tearing, redness (due to conjunctival hyperaemia and episcleral vascular injection) and hyphaema.
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10.26 Extensive hyphaema in a dog.
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10.27 Anterior lens luxation in a dog. The entire lens equator can be seen, and the lens partially covers the iris.
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10.29 (a) Fundoscopic image of a cat with blindness due to hypertensive retinopathy. Note the diffuse retinal oedema, multifocal retinal haemorrhages (black arrows), ventral retinal detachment (white arrows) and mild retinal vascular tortuosity. (b) The same eye 2 months after treatment with amlodipine. Note the substantial resolution of the retinal oedema, retinal haemorrhages and retinal detachment. The vision of this patient was recovered.
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10.30 Bullous retinal detachment in a cat with systemic hypertension. (Reproduced from with permission from )
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10.31 (a) Toxic neuroretinitis in a dog with acute blindness after accidental ingestion of ivermectin. Note the comma-shaped pigmentary changes in the tapetal fundus. In the non-tapetal fundus there are multiple areas of retinal oedema. (b) The dog recovered vision spontaneously 24 hours after presentation.
Image of 10.32
10.32 Severe optic neuritis in a cat with cryptococcosis. The optic nerve head appears swollen, oedematous, congestive, and with blurred margins. Several retinal and optic nerve haemorrhages are also present. (Courtesy of C Peruccio)

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