Practically perfect ophthalmology tips

Veterinary ophthalmology can feel intimidating in a busy general practitioner (GP) settings—but it doesn’t have to. In this Vet Blast Podcast episode, host Adam Christman, DVM, MBA, sits down with Kenneth Pierce, DVM, MS, DACVO, to break down practically perfect approaches to everyday eye problems.

From confidently distinguishing cataracts from nuclear sclerosis with a simple dilated exam to prioritizing therapies for corneal ulcers and spotting true ophthalmic emergencies like glaucoma, corneal lacerations, and melting ulcers, Pierce offers practical, step-by-step guidance any clinician can use.

Below is a partial transcript, edited lightly for clarity.

Adam Christman, DVM, MBA: All right, so let's talk about one of the most common conditions that we see as primary care veterinarians, and that's cataracts, without a doubt. Sometimes you can get a little overwhelmed, sometimes you get it confused with nuclear or lenticular sclerosis. So, what are some [of the] best clinical management strategies GPs can implement for patients developing cataracts?

Kenneth Pierce, DVM, MS, DACVO: Yeah, so the very first thing is take the time to dilate them, right? Obviously, we're getting busy in our day, and we're looking at this eye, but have your nursing team be able to evaluate the initial diagnostic test for eye exam, and get them dilated right away, as long as the pressure isn't elevated and they have normal PLRs, you should be able to dilate anybody and everybody. And then after that, 15 minutes of dilation with tropicamide, then go back in and take a look with your transilluminator, whatever light source that you have from a distance, as well as up close.

So, from a distance, when you're trying to differentiate nucleus sclerosis from cataracts, you should get the computer reflection through the eye. The nucleus sclerosis is going to dull it down just a little bit in the center, so it's going to look like a dull pearl, but you still get that reflection through it, as well as a brighter reflection around it.

Anything that is a cataract from a distance is going to block that reflection, so it's actually going to look like a black spot amongst the reflection. When you get close, and this is where a lot of GPs get tripped up, especially when they don't dilate the pupil, is that when you shine the light closer to the eye, that nucleolus sclerosis scatters light, which is why people, as well as animals, have difficulties with seeing, you know, when it's super bright. So it's gonna scatter light is going to make the lens turn more white, which is actually going to look more like a cataract, and so that is why there's a little bit of people get tripped up and say, ‘Oh, your pet has cataracts,’ when sometimes you get the report back, and you're like, ‘It's just nucleolus sclerosis, and there is no cataract there.’ So, take the time to dilate.

Then, if you do identify cataracts, it's worth just like you do for your PCP. Once you've identified a problem, get them to an ophthalmologist, just in general, so the ophthalmologist can give the owner options. Depending on the location and how the cataract looks, and things like that, there's information that we could tell them, as far as if this cataract at that location is likely to progress or not, what the etiology is, if there's things that we need to kind of implement to prevent it from getting worse, or to address whatever the underlying cause is that's caused it in the first place. And then definitely, if you've identified cataract along with an IOP drop, and so let's say in the affected eye the pressure is like 7, but in the non-affected eye the pressure is like 17—where it should be—that's a drastic difference between the 2 eyes, and there should only be just a 5 millimeter of mercury difference between the eyes. So that lower IOP can be an indication of lens-induced uveitis, and in that situation you will want to start some form of topical anti-inflammatory.

So kind of keeping those things in mind, but definitely you know, when you do refer a case to an ophthalmologist, you're not losing that client, you're just basically giving them the additional information that they need to be informed about what's going to happen to that eye over time.