Equine Recurrent Pain Photophobia Uveitis ... · equine recurrent uveitis with single port pars plana vitrectomy. Vet Ophthalmol 1:137-151, 1998 Vitrectomy ... ERU BW.ppt Author:

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Equine RecurrentEquine RecurrentUveitisUveitis

David A. Wilkie, DVM, MS,David A. Wilkie, DVM, MS,Diplomate ACVODiplomate ACVO

The Ohio State UniversityThe Ohio State University

ERU Clinical Signs - ActiveERU Clinical Signs - Active PainPain PhotophobiaPhotophobia BlepharoedemaBlepharoedema MiosisMiosis Aqueous flareAqueous flare Keratitic Keratitic precipitatesprecipitates HypotonyHypotony ChorioretinitisChorioretinitis

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ERU Clinical Signs - ChronicERU Clinical Signs - Chronic SynechiaSynechia CataractCataract PhthisisPhthisis bulbi bulbi Corpora nigra atrophyCorpora nigra atrophy Peripapillary depigmentationPeripapillary depigmentation GlaucomaGlaucoma Retinal detachmentRetinal detachment BlindnessBlindness

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ERU

Equine Motor Neuron Disease

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Etiology of UveitisEtiology of Uveitis

Primary ocularPrimary ocular Corneal ulcer, cataract, traumaCorneal ulcer, cataract, trauma

Etiology of UveitisEtiology of Uveitis

SystemicSystemic SepticemiaSepticemia ViremiaViremia ParasiticParasitic ImmuneImmune

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UveitisUveitis

Foals with neonatal septicemia areFoals with neonatal septicemia areespecially prone to anterior andespecially prone to anterior andposterior uveitisposterior uveitis

UveitisUveitis Foals with neonatal septicemia are especiallyFoals with neonatal septicemia are especially

prone to anterior and posterior uveitisprone to anterior and posterior uveitis Uveitis in these foals is usually sterileUveitis in these foals is usually sterile

UveitisUveitis Foals with neonatal septicemia are especially proneFoals with neonatal septicemia are especially prone

to anterior and posterior uveitisto anterior and posterior uveitis Uveitis in these foals is usually sterileUveitis in these foals is usually sterile Copious fibrin production may be a consequence ofCopious fibrin production may be a consequence of

anterior uveitis, especially in young foalsanterior uveitis, especially in young foals

UveitisUveitis Foals with neonatal septicemia are especially proneFoals with neonatal septicemia are especially prone

to anterior and posterior uveitisto anterior and posterior uveitis Uveitis in these foals is usually sterileUveitis in these foals is usually sterile Copious fibrin production may be a consequence ofCopious fibrin production may be a consequence of

anterior uveitis, especially in young foalsanterior uveitis, especially in young foals Intracameral Intracameral tissuetissue plasminogen plasminogen activatoractivator

25-75 µg25-75 µg

Fibrinous UveitisFibrinous Uveitis 4 Hours Post TPA4 Hours Post TPA

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Equine Recurrent UveitisEquine Recurrent Uveitis

moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia

Equine Recurrent UveitisEquine Recurrent Uveitis moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia most common cause of blindness in horsesmost common cause of blindness in horses

Equine Recurrent UveitisEquine Recurrent Uveitis moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia most common cause of blindness in horsesmost common cause of blindness in horses Appaloosa has been shown to be a predisposedAppaloosa has been shown to be a predisposed

breedbreed


breedbreed 8 fold increase in risk in the Appaloosa as8 fold increase in risk in the Appaloosa as

compared with other breedscompared with other breeds


breedbreed 8 fold increase in risk in the Appaloosa as8 fold increase in risk in the Appaloosa as

compared with other breedscompared with other breeds ERU affected AppaloosaERU affected Appaloosa’’s are 4 times more likelys are 4 times more likely

to loose vision than ERU affected non-to loose vision than ERU affected non-AppaloosaAppaloosa’’ss


Immune-mediated disease withImmune-mediated disease withnumerous initiating or exacerbatingnumerous initiating or exacerbatingfactorsfactors

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Immune-mediated disease withImmune-mediated disease withnumerous initiating or exacerbatingnumerous initiating or exacerbatingfactorsfactors

Frequency and severity of eachFrequency and severity of eachrecurrence are extremely variablerecurrence are extremely variable


HorsesHorses seropositive seropositive for for Leptospira Leptospirainterogans serovarinterogans serovar pomona are 13 pomona are 13times more likely to develop ERU thantimes more likely to develop ERU thannon-non-seropositive seropositive horseshorses


Horses seropositive for LeptospiraHorses seropositive for Leptospirainterogans serovar pomona are 13interogans serovar pomona are 13timestimes more likely to develop ERU than more likely to develop ERU thannon-non-seropositive seropositive horseshorses

seropositive seropositive horses are 4.5 times morehorses are 4.5 times morelikely to have ERU result in blindnesslikely to have ERU result in blindnessthan non-than non-seropostive seropostive horseshorses

Worst CaseWorst Case Senario Senario

Leptospira interogans serovar Leptospira interogans serovar pomona positivepomona positive

TreatmentTreatment

Suppression of inflammationSuppression of inflammation Control of painControl of pain Prevention of Prevention of sequelaesequelae

Nonspecific TherapyNonspecific Therapy

AtropineAtropine

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Nonspecific TherapyNonspecific Therapy AtropineAtropine NSAIDNSAID’’ss

SystemicSystemic TopicalTopical



CorticosteroidsCorticosteroids SystemicSystemic TopicalTopical



CorticosteroidsCorticosteroids SystemicSystemic TopicalTopical

CyclosporinCyclosporin TopicalTopical IntraocularIntraocular

AtropineAtropine As needed to dilateAs needed to dilate

the pupilthe pupil Not more thanNot more than

4x/day4x/day

SystemicSystemic NSAID NSAID’’ss BanamineBanamine PhenybutazonePhenybutazone AspirinAspirin

CorticosteroidsCorticosteroids Care with topicalCare with topical

use and cornealuse and cornealdiseasedisease

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Topical Topical Cyclosporin Cyclosporin AA Limited cornealLimited corneal

penetrationpenetration

Surgical Management of ERUSurgical Management of ERU

IntravitrealIntravitreal//Suprachoroidal Suprachoroidal placementplacementof a sustained-releaseof a sustained-release cylosporine cylosporineimpregnated deviceimpregnated device

VitrectomyVitrectomy

CyclosporinCyclosporin Gilger Gilger BC, Wilkie DA, et al: Use of anBC, Wilkie DA, et al: Use of an

intravitreal intravitreal sustained-release cyclosporinesustained-release cyclosporinedelivery device for treatment of equinedelivery device for treatment of equinerecurrent uveitis. Am J Vetrecurrent uveitis. Am J Vet Res Res 62:1892-1896,62:1892-1896,20012001

Gilger Gilger BC,BC, Malok Malok E, et al: Lon-term effect onE, et al: Lon-term effect onthe equine eye of anthe equine eye of an intravitreal intravitreal device useddevice usedfor sustained release of cyclosporine A. Vetfor sustained release of cyclosporine A. VetOphthalmol Ophthalmol 3:105-110, 20003:105-110, 2000

Wilkie DA,Wilkie DA, Gemensky Gemensky AJ, et al:AJ, et al: Intravitreal Intravitrealcyclosporin cyclosporin A implantation for equineA implantation for equinerecurrent uveitis. Vetrecurrent uveitis. Vet Ophthalmol Ophthalmol 4:292, 20014:292, 2001

Intravitreal CyclosporinIntravitreal Cyclosporin

Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitrealCsA implantCsA implant

Intravitreal CyclosporinIntravitreal Cyclosporin Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitreal CsACsA

implantimplant decrease the frequency and severity ofdecrease the frequency and severity of

recurrent uveitis episodesrecurrent uveitis episodes



recurrent uveitis episodesrecurrent uveitis episodes 23 horses with a mean follow-up of 1-2923 horses with a mean follow-up of 1-29

months (mean 10.5 +/- SD 7.6 months)months (mean 10.5 +/- SD 7.6 months)

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recurrent uveitis episodesrecurrent uveitis episodes 23 horses with a mean follow-up of 1-2923 horses with a mean follow-up of 1-29

months (mean 10.5 +/- SD 7.6 months)months (mean 10.5 +/- SD 7.6 months) 18/23 (78.2%) remain visual at the time of18/23 (78.2%) remain visual at the time of

follow-up.follow-up.

Intravitreal CyclosporinIntravitreal Cyclosporin Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitreal CsA implantCsA implant decrease the frequency and severity of recurrentdecrease the frequency and severity of recurrent

uveitis episodesuveitis episodes 23 horses with a mean follow-up of 1-29 months23 horses with a mean follow-up of 1-29 months

(mean 10.5 +/- SD 7.6 months)(mean 10.5 +/- SD 7.6 months) 18/23 (78.2%) remain visual at the time of follow-18/23 (78.2%) remain visual at the time of follow-

up.up. Complications include glaucoma and retinalComplications include glaucoma and retinal

detachment, both of which may relate to ERUdetachment, both of which may relate to ERU

Intravitreal CyclosporinIntravitreal Cyclosporin Dorsal approachDorsal approach

Resect Resect conjunctivaconjunctiva Lateral to dorsalLateral to dorsal rectus rectus musclemuscle 6-8 mm posterior to limbus6-8 mm posterior to limbus Stab incisionStab incision Implant device and anchor to scleraImplant device and anchor to sclera

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Placement ofPlacement ofSuprachoroidal Suprachoroidal CsACsA

Matrix implantMatrix implantBrian C.Brian C. Gilger Gilger

NCSUNCSU

Suprachoroidal Suprachoroidal Placement ofPlacement ofMatrix / Reservoir CsA DeviceMatrix / Reservoir CsA Device

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Suprachoriodal Suprachoriodal Placement ofPlacement ofMatrix / Reservoir CsA DeviceMatrix / Reservoir CsA Device

6mm

8-10 mm

7 mm

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VitrectomyVitrectomy

Fruhauf Fruhauf B,B, Ohnesorge Ohnesorge B,B, Deegen Deegen E,E,Boeve Boeve M: Surgical management ofM: Surgical management ofequine recurrent uveitis with singleequine recurrent uveitis with singleport parsport pars plana vitrectomy plana vitrectomy. Vet. VetOphthalmol Ophthalmol 1:137-151, 19981:137-151, 1998

VitrectomyVitrectomy ParsPars plana vitrectomy plana vitrectomy

invasive surgery,invasive surgery,requiring morerequiring moreinstrumentation andinstrumentation andexpertise and isexpertise and isassociated withassociated withsignificantsignificantpost-operativepost-operativevision threateningvision threateningcomplicationscomplications

VitrectomyVitrectomy ParsPars plana vitrectomy plana vitrectomy, as compared with, as compared with intravitreal intravitreal

CsA implantation is a more invasive surgery,CsA implantation is a more invasive surgery,requiring more instrumentation and expertise and isrequiring more instrumentation and expertise and isassociated with significant post-operative visionassociated with significant post-operative visionthreatening complications.threatening complications.

It does appear however to decrease the severity andIt does appear however to decrease the severity andfrequency of ERU episodesfrequency of ERU episodes

VitrectomyVitrectomy ParsPars plana vitrectomy plana vitrectomy, as compared with, as compared with intravitreal intravitreal

CsA implantation is a more invasive surgery,CsA implantation is a more invasive surgery,requiring more instrumentation and expertise and isrequiring more instrumentation and expertise and isassociated with significant post-operative visionassociated with significant post-operative visionthreatening complications.threatening complications.

It does appear however to decrease the severity andIt does appear however to decrease the severity andfrequency of ERU episodesfrequency of ERU episodes

ComplicationsComplications CataractCataract Retinal detachmentRetinal detachment

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PrognosisPrognosis varies according to:varies according to:

severity of uveitis severity of uveitis duration of episodesduration of episodes response to treatmentresponse to treatment frequency of recurrencefrequency of recurrence

reduced in Appaloosa horses and in horsesreduced in Appaloosa horses and in horsesseropositive seropositive forfor Leptospira interogans Leptospira interogansserovar serovar pomonapomona

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Equine Recurrent Pain Photophobia Uveitis ... · equine recurrent uveitis with single port pars plana vitrectomy. Vet Ophthalmol 1:137-151, 1998 Vitrectomy ... ERU BW.ppt Author: