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Complicated corneal ulcer: Avoiding disasters (Proceedings)

August 1, 2008
Steve Sisler, DVM, DACVO

The primary goal in treating a corneal ulcer is to identify its cause or identify factors that may prevent it from healing well.

Corneal Anatomy

1. Corneal erosion: Superficial: Epithelium

2. Corneal ulcer: Middle: Stroma

3. Descemetocoele: Deep: Endothelium and Descemet's membrane

Most Corneal Ulcers Occur for a Reason

1. Abnormal tear film

2. Abnormal blink motion

3. Decreased corneal sensation

4. Abnormal hairs

5. Inflammation

6. Immune-mediated

7. Degenerative

The primary goal in treating a corneal ulcer is to identify its cause or identify factors that may prevent it from healing well. Therefore a thorough ocular examination should be performed on any patient with an ulcer.

1. Eyelids:

a. Distichia- breed predisposition

b. Ectopic cilia- young dogs, very painful, dorsal erosion

c. Trichiasis- entropion

d. Meibomitis?

2. Conjunctiva

a. Follicles

3. Cornea

a. ulcer depth

b. ulcer character (malacic, infected, indolent)

4. Anterior chamber

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a. uveitis (primary or reflex?)

5. Iris

a. Miosis

b. iritis

6. Lens

a. pathology?

7. Posterior segment

a. abnormalities?

Ophthalmic Tests

1. Schirmer Tear Test

a. Normal 15-25, but brachycephalic?

2. fluorescien stain

a. Stains stroma only, will delineate ulcer size

b. TFBUT >20 seconds

c. Undermining epithelial lip?

3. Tonometry

a. Ulcers can commonly occur secondary to rubbing from glaucoma discomfort.

Ulcer Management

1. Treat the underlying cause.

- Surgery for hair removal

- Tear stimulant therapy

- Glaucoma therapy

2. Manage concurrent problems.

- Systemic antibiotics

- Systemic anti-inflammatories

3. Choose antibiotic therapy based on severity of ulcer and predisposition to get worse.

- Triple antibiotic or Gentocin good first line defense

- Tobramycin for pseudomonas infections

- Tobramycin AND Ofloxacin for complicated ulcers

- Plasma for malacic ulcers

4. Consider supportive care.

- Tear replacement therapy

5. Determine if depth warrants surgical correction. (>50% consider)

- Conjunctival pedicle graft

- Cornealconjunctival transposition

- Island graft

- Artificial membrane tissue graft

Miscellaneous tips:

1. If an ulcer is not healing- simply changing antibiotics is not the best approach!

2. Remember atropine will decrease tear production- only use if needed.

Various Complicated Ulcers

Corneal degeneration

- Age related, usually no breed predisposition

- mineral accumulation resulting in corneal tissue sloughing

- Difficult to heal with medication

- Trichlorocetic acid debridement or CPG

Endothelial degeneration

- Age related, breed predisposed (dalmation, dachshund, boston terrier)

- Loss of endothelial cells resulting in accumulation of edema in cornea

- Results in mild to moderate loss of vision

- Can cause corneal bullae and subsequent ulcers and erosions.

- Sodium chloride ointment can slow progress of disease

- Erosions and recurrent bullae treated with laser keratoplasty

Multiple superficial punctuate keratitis

- Breed related (usually Shetland Sheepdog)

- Immune-mediated disease with mulitfocal erosions

- Immunosuppressive therapy required, often for life

Herpes corneal erosions

- Feline chronic issues, epithelial in nature

- Client education is a large treatment!

- Topical antivirals may be necessary

- Preventative therapy includes Genteal gel and L-Lysine

Indolent erosions

- Diagnostic undermining of erosion edges, do not need recurrence

- Q-tip debridement, linear grid keratotomy, multiple punctuate

- keratotomy, superficial keratectomy

Corneal foreign bodies

- Typically removal out the entrance wound

- Beware of possible AC penetration, be prepared for corneal wound surgery

- Very close examination to determine if ANY lens involvement—may need phacoemulsification

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