Upload
others
View
6
Download
0
Embed Size (px)
Citation preview
2/12/19
1
Anterior Uvea & LensDavid A. Wilkie DVM, MS, Diplomate ACVO
Professor EmeritusThe Ohio State University
The Red, The Cloudy, The Painful
The eye is the “window” to systemic information
The eye has the highest blood flow by weight of any organ
Uveitis
n Clinical Signsn Anteriorn Posterior
Anterior Uveitisn Miosis
Anterior Uveitisn Miosisn Flare
2/12/19
2
Anterior Uveitisn Miosisn Flaren Redness
Anterior Uveitisn Miosisn Flaren Rednessn Photophobia
Anterior Uveitisn Miosisn Flaren Rednessn Photophobian Pain
Anterior Uveitisn Miosisn Flaren Rednessn Photophobian Painn Keratic precipitates
Anterior Uveitisn Miosisn Flaren Rednessn Photophobian Painn Keratic precipitatesn Hypotony
2/12/19
3
Posterior Uveitisn Chorioretinitis
n Hemorrhagen Vaculitisn Edeman Transudaten Exudate
Anterior Uveitisn Etiologies
n The etiologies of anterior uveitis can be either ocular or systemic.
OcularSystemic
Uveitis
Anterior Uveitisn Ocular Etiologies
n There are only 4 main ocular causes, rule them out first
Anterior Uveitis
n Ocular: n Corneal
ulceration
Anterior Uveitis
n Ocular: n Corneal
ulcerationn Lens-induced
Anterior Uveitis
n Ocular: n Corneal
ulcerationn Lens-inducedn Ocular trauma
2/12/19
4
Anterior Uveitisn Ocular:
n Corneal ulceration
n Lens-inducedn Ocular trauman Neoplasia
n primary
Anterior Uveitisn Neoplasia
n Primary vs secondary
Lymphosarcoma
Ciliary adenoma
Anterior Uveitisn Etiologies
n The etiologies of anterior uveitis can be either ocular or systemic.
OcularSystemic
Uveitis
X
Uveitis
BacteremiaSepticemia
ViremiaMycotic
Metastatic neoplasiaAutoimmune
Anterior Uveitisn Systemic Etiologies:
n Bacteremia, viremia, or septicemian Autoimmunen Metastatic neoplasian A complete physical examination is
therefore essential.
Uveitis
n Where does you patient live?n Travel history?
2/12/19
5
Canine Uveitisn Idiopathic / Immune-mediated (58%)n Neoplasia (24.5%)n Systemic infectious disease (17.5%)
Massa KL, et al. Causes of uveitis in dogs: 102 Cases (1989-2000) Veterinary Ophthalmology
Blasto Heartworm
Lymphosarcoma
Lyme
Multiple myeloma Erhlichia
Histiocytic Sarcoma
Uveo-Dermatologic Syndrome Erlichia
Blastomycosis Cryptococcosis
2/12/19
6
Cryptococcosis
Optic neuritis
Canine Rocky Mountain Spotted Fever
Parasitic MigrationAngiostrongylus
Courtesy of Dr. Tim Knott
Systemic Infectious Disease n Other
n Protothecosisn Aspergillosisn Bartonellosisn Infectious Canine Hepatitisn Brucella canisn Lymes disease
Ocular Oncology
Primary - intraocular Secondary - intraocular
Melanoma LymphosarcomaAdenoma/Adenocarcinoma CarcinomaSpindle cell sarcoma - cat Sarcoma
2/12/19
7
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Canine Neoplastic UveitisMultiple Myeloma
Canine Neoplastic UveitisHistiocytic Sarcoma
Lymphosarcoma
Feline Uveitisn Idiopathic / Immune-mediated (33-58%)n Neoplasia (13-23%)n Systemic infectious disease (24-83%)
Feline Infectious Disease• FELV (12%)• FIP (5-19%)• Toxo (5-75%)• FIV (13-21%)• Crypto (2%)• Bartonella
Cat may have more than one of these
2/12/19
8
Crypto
FeLV
FIP
FIP
Toxo
FIV
Anterior Uveitis - systemicn Diagnostic Tests
n History - Duration, progression of diseasen Physical examination n Complete blood countn WBC count, Differentialn Platlet count
Anterior Uveitisn Diagnostic Tests
n Biochemical profilen Serologyn Radiologyn Ultrasoundn Cytology/Histopathology
Anterior Uveitis
n Serology – REMEMBER CO-INFECTIONSn Blasto, Histo, Crypto n RMSF, Erlichia canis/platys, Lymes, ICH,
Distempern FeLV, FIV
n Toxo - request IgG, IgM, and Toxo antigen tests
n Bartonellan Leishmania
Uveitis - Things to remembern Canine uveitis
n Idiopathic (58%)n Neoplasia (24.5%)n Systemic infectious
disease (17.5%)
n Feline uveitisn Idiopathic (33-58%)n Neoplasia (13-23%)n Systemic infectious
disease (24-83%)
Therefore, in approximately 50% of cases in both dogs and cats, there is a systemic disease causing the uveitis.
Sequelae of Anterior Uveitisn Anterior &/or posterior synechian Cataractn Glaucoman Blindnessn Phthisis bulbi
2/12/19
9
Glaucoma Glaucoman Is the glaucoma primary or secondary?
Glaucoman Is the glaucoma primary or secondary?n Is it acute or chronic?
AcuteChronic
Glaucoma
Intraocular Pressure Determination
n There are 3 specific ways to determine intraocular pressure: n Indentation tonometry n Applanation tonometryn Rebound tonometry
Primary Glaucoman Not associated with
any other ocular disease
n No antecedent cause
Primary Glaucoman This is generally seen in predisposed
breeds:n Poodle, Basset hound, Beagle, Afghann American & English Cocker Spanieln English Springer Spanieln Artic breeds - Husky, Elkhound, Samoyed, etc.n Shar-Pei, Chow Chow, Dalmation, Bouvier, Other
2/12/19
10
Primary Glaucoman predisposed to bilateral involvementn bilateral involvement is 50% within 2
years
Primary Glaucoman predisposed to bilateral involvementn bilateral involvement is 50% within 2 yearsn unaffected eye requires preventive therapy
n IOP monitoringn Prophylactic Rx
Secondary Glaucoman The result of some other event in the
eye which results in a decrease in aqueous humor access to the drainage angle or a decrease in outflow
Secondary Glaucoman Etiologies
n Anterior lens luxation
Secondary Glaucoman Gene for PLL identified at University of
Missouri and AHTn Simple recessive traitn Homozygous affected luxated by 4-8 yrn 30% develop glaucoma
2/12/19
11
Secondary Glaucoman Etiologies
n Anterior lens luxation
n Synechia
Secondary Glaucoman Etiologies
n Anterior lens luxation
n Uveitis
Hypermature cataract, Lens-induced uveitis, Secondary glaucoma
Why does this happen?
PIFM
Secondary Glaucoman Etiologies - PIFM
n Pre-iridal fibrovascular membranen Uveitis #1n Intraocular Neoplasian Retinal Detachment
PIFM
§Chronic uveitis§Intraocular neoplasia§Retinal detachment/degeneration
Normal Iris
Glaucoma PIFM�s
2/12/19
12
RednessDeep corneal vesselsDilated PupilDiffuse Corneal Edema
Acute Primary GlaucomaInfarction secondary to acute glaucoma
Acute Glaucoman Treatment
n Personal preference:n Latanoprostn Mannitol if
latanoprostineffective
n Topical and Systemic CAI
n Referral for Sx
Acute Glaucoman Treatment
n Prostaglandinsn Latanoprost
0.005% (Xalatan)
Miosis
Passive Paracentesis – 30 guage needleAcute Glaucoma
n Treatmentn Topical CAI’s
Dorzolamide reaction
2/12/19
13
Acute Glaucoman TransScleral
CycloPhotocoagulation
TSCPSuccess at 1 year:
Canine: 50-60%Equine: >80%
Endocyclophotocoagulation (ECP)
Success at 1 year:Canine: >80%
Lens
Iris
Laser targets Ciliary Processes
2/12/19
14
Success at 1 year:Canine: >80%
Ahmed glaucoma shunt
Chronic Glaucoman These are not
emergencies as is the case with the acute patient
n Treatmentn Prosthesisn Enucleationn Pharmacologic
ablation
2/12/19
15
Chronic Glaucoman Treatment
n Eviseration with Prosthesis n Remove internal contents of the globen Insert a 19mm silicone spheren Cornea will vascularize over the next 2-4
weeks.
http://youtu.be/lF0bOb42oNs
K9 Intrascleral Prosthesis
K9 ISP 1 week post-op K9 ISP 2 week post-op
K9 ISP 10 week post-op K9 ISP 1 year post-op
2/12/19
16
K9 ISP OU 2 yr post-op K9 ISP OD, enucleation OS 1 yr post-op
Cataract Etiology of Cataractsn Hereditaryn Metabolicn Inflammatoryn Traumaticn Toxicn Nutritionaln Radiationn Electric
Canine
Feline
Cataract - locationn Location
n Capsular
Cataract - locationn Location
n Capsularn Cortical
2/12/19
17
Cataract - locationn Location
n Capsularn Corticaln Nuclear
Cataract - locationn Location
n Capsularn Corticaln Nuclearn Equatorial
Cataractn Age of onset
n Congenitaln at birth
n Developmentaln < 6yr
n Senilen >6-9yr
Cataract - severityn Progression
n Incipient
Cataract - severityn Progression
n Incipientn Immature
2/12/19
18
CataractEquatorial vacuoles - immature
CataractPosterior cortical - immature
Cataract - severityn Progression
n Incipientn Immaturen Mature
CataractMature cataract
2/12/19
19
Cataract - severityn Progression
n Incipientn Immaturen Maturen Hypermature
Hypermature
J. Mould
Hypermature
Mature Hypermature
Hypermature
J. Mould
Hypermature with Retinal detachment
Hypermature cataract with LIU Lens induced uveitis
2/12/19
20
Lens induced uveitis with secondary glaucomaOcular Ultrasound
Normal eye 10 mHz
Lens
Vitreous
IrisAnterior Chamber
EOM
Cataract Surgeryn Ultrasound
n Vitreous Degenerationn Immature - 2%nMature - 7%nHypermature - 20%
Cataract
Vitreous degeneration
2/12/19
21
Vitreous degeneration
Cataract Surgeryn Ultrasound
n Retinal Detachmentn Immature - 2%nMature - 5%nHypermature - 12-15%
Cataract
Retinal detachment
Retinal detachment
Cataract
Retinal detachment
Cataract Surgeryn Electroretinogram
n Awake or under anesthesia
2/12/19
22
Photopic
Scotopic
Cataract – why surgery?n 3 options for vision significant cataracts
n 1. Surgery – phacoemulsification + IOLn Best outcome
n 2. Anti-inflammatory treatment; No surgeryn Failure 4x greater than #1
n 3. No treatment; No surgeryn Failure 255x greater than #1
n Failure 65x greater than #2
Lim C, et al: Cataracts in 44 dogs (77 eyes): A comparision of outcomes for no treatment, medical management, or phacoemulsification with IOL. Can Vet J 52:283-288, 2011
When to Refer?n Referral should be
done earlyn We no longer wait
for a mature “ripe” cataract
n Refer early immature and all cataracts that are progressive
Aphakia -14D
EmmetropiaSir HaroldRidley
2/12/19
23
1 Year - old DogPhaco -8 sec, 50ml
AcriVet 60V IOL
2 yr post op IOL�s
Questions?