Ocular emergencies (Proceedings)

An emergency involves anything that is vision-threatening and/or painful for the patient.

Ulcers: Melting and deep corneal ulcers or descemetoceles should be treated aggressively and hospitalization for appropriate treatment may be required. Surgery is generally recommended for these ulcers, however medical treatment may be necessary based on the owner's financial situation, the health status of the patient, or if the patient needs to be stabilized overnight. A basic treatment protocol is outlined:

• Melting

o Topical antibiotics q 2 hr (Zymar+tobramycin)

o + serum q 1 hr

o Tropicamide q 8 hr

o Topical lubricant q 1 hr

o Oral doxycycline and Clavamox PO q 12 hr

o Oral anti-inflammatory

• Deep/descemetocoele/rupture

o Topical antibiotic q 2 hr (Zymar)

o + atropine q 8 hr

o Lubricant q 1 hr

o + serum q 1 hr

o Oral doxycycline and Clavamox PO q 12 hr

o Oral anti-inflammatory

o NO ointments

Lacerations: Corneal lacerations that are simple may self-seal and require only medical treatment. Lacerations in which a flap exists may need surgery and depending on the size and location may be treated with a biomaterial, debridement and suturing of the cornea, or a conjunctival pedicle graft or corneal:conjunctival transposition. This basic protocol for medical treatment may also be used post-surgically:

• Topical antibiotic q 2 hr

• Atropine q 8 hr

• Topical lubricant q 2 hr

• Oral antibiotic PO q 12 hr

• Oral anti-inflammatory

• NO ointments

Corneal Foreign Bodies: Foreign bodies often require surgery in which case the foreign body should be cut out of the cornea disturbing as little intact cornea as possible. Surgical options are similar to the those discussed for lacerations.

• Same treatment as for corneal lacerations

• DO NOT pull objects out of the cornea

• If superficial, flush with steady stream of saline

Glaucoma=IOP > 25 mmHg. All cases of glaucoma require immediate treatment since permanent damage to the neurosensory retina may occur in as little as 30 minutes. Emergency treatment options are outlined below and if the eye is non-responsive the patient should be referred for further treatment and surgery. For those cases that respond to emergency treatment referral is still recommended on a non-emergent basis to perform gonioscopy and assess the risk to the contralateral eye.

• IOP < 30 mm Hg

o Xalatan

o Wait 30 min and recheck IOP

o Meds

• Methazolamide 1 mg/lb PO q 12 hr

• Topical anti-inflammatory (NPD q 12 hr)

• Topical Azopt or Trusopt

o Recheck IOP in 12 hr

• IOP > 30 mm Hg

o Glycerin PO (0.75 ml/lb)

o Mannitol iv (1 gm/kg over 15-20 minutes)

o Xalatan

o Azopt or Trusopt

o Timolol, 0.5%

o Recheck IOP q 30 min

o Namenda – 5mg for large dogs, 2.5 mg for small dogs PO q24hrs

o If response with IOP less than 25 mm Hg discharge on previous meds

o Re-examination 12 hr (next day)

• If no response to meds recommend referral and call

• For prognosis try to determine if acute or chronic

o Check for corneal neovascularization

o History from owner

• Cycloablation (cyclocryoablation or cyclophotoablation or endolaser cyclophotoablation)

• Gonioimplantation

Uveitis: or intraocular inflammation may be challenging to treat. Broad spectrum medications should be started immediately, then adjusted followed evaluation of diagnostic results.

• Topical and oral anti-inflammatories

o May need topicals q 2 hr

o Pred forte (proprietary) and/or flurbiprofen (4-8x/day)

o Rimadyl or pred PO

• Subconjunctival injection of triamcinolone or betamethasone

• Topical and oral antibiotics (usually doxy-5mg/kg))

• + mydriatics

• Topical lubricants q 4 hr

• Evaluate history, bloodwork, imaging to determine etiology

Hyphema and uveitis

• Treat as for uveitis

• Concern re: glaucoma

• Also, check consensual PLR

• Rec ocular ultrasound, blood pressure, and bloodwork

Proptosis: 66% have a poor prognosis for vision, but good cosmesis is possible; the prognosis deteriorates if more than 2 extraocular muscles are torn and patients usually need additional surgery to address exposure, especially since secondary KCS is a problem in these cases.

• Lubricate immediately

• Under anesthesia/deep sedation replace globe and place temporary tarsorrhaphy sutures ASAP

• Topical antibiotics and lubricants

• Oral antibiotics

• Oral anti-inflammatories

• Recheck 1-2 weeks

Lens luxation (anterior): surgery is the treatment of choice and should be performed as soon as possible to decrease the sequelae of secondary glaucoma, corneal endothelial degeneration, and associated uveitis.

• Normal IOP

o Anti-inflammatories

o Prophylactic glaucoma med

o Surgery tomorrow

• Increased IOP

o Treat for glaucoma

o Avoid xalatan if lens is situated in the pupillary aperture

o Anti-inflammatories

o Surgery ASAP