Practically perfect ophthalmology tips

Veterinary ophthalmology can feel intimidating in a busy general practitioner (GP) setting, but it doesn’t have to. In this episode of The Vet Blast Podcast, 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 such as glaucoma, corneal lacerations, and melting ulcers, Pierce offers practical, step-by-step guidance that any clinician can use.

Below is a partial transcript, edited lightly for clarity.

Adam Christman, DVM, MBA: 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: The very first thing is [to] take the time to dilate them. We're getting busy in our day, and we're looking at this eye, but have your nursing team…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. 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 [and] up close.

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—when you shine the light closer to the eye, that nucleolus sclerosis scatters light, which is why people [and] animals have difficulties with seeing when it's super bright. So it's…going to make the lens turn more white, which is actually going to look more like a cataract. So that is why [some] 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.

If you do identify cataracts…get them to an ophthalmologist…so the ophthalmologist can give the owner options. Depending on the location and how the cataract looks…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 are things that we need to implement to prevent it from getting worse, or to address whatever the underlying cause is that caused it in the first place. And then definitely, if you've identified cataract along with an IOP drop—let's say in the affected eye, the pressure is 7, but in the nonaffected eye, the pressure is 17—where it should be. That's a drastic difference between the 2 eyes, and there should only be a 5-mm Hg 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…keep those things in mind. But…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.