Veterinary Ophthalmology Referral Report

Veterinarian Thank you for referring this patient to Animal Eye Care Specialists. Referring Veterinarian: Dr. Sarah Jenkins, Paws & Claws Veterinary Clinic, 123 Pet Lane, Anytown, UK Patient Information: Buddy, Smith, Canine, Golden Retriever, 7 years old, Male Neutered Date of Examination: 1 November 2024 Reason for Referral: Buddy was referred due to a chronic history of left eye redness and discomfort, which has been unresponsive to previous topical antibiotic treatment. The referring veterinarian noted a progressive cloudiness in the cornea over the past month and suspected a corneal ulcer that was not healing as expected. History: Buddy has a medical history of seasonal allergies managed with oral antihistamines. The current ocular symptoms began approximately three months ago with mild conjunctivitis, which initially improved with a course of topical tobramycin. However, the condition relapsed, and the left eye became more inflamed and painful, leading to increased tearing and squinting. There is no known history of ocular trauma. Buddy is otherwise healthy, up-to-date on vaccinations, and on a regular flea and worming programme. His owner reports no changes in appetite or behaviour, aside from ocular discomfort. Clinical Examination Findings: Visual assessment revealed a menace response present in the right eye but absent in the left eye. Pupillary light reflexes were direct and consensual in both eyes, though slower in the left. External examination of the left eye showed significant blepharospasm, epiphora, and conjunctival hyperaemia. The cornea exhibited a central, deep stromal ulcer approximately 4mm in diameter with surrounding oedema and neovascularisation extending from the limbus. A discrete descemetocele was observed at the centre of the ulcer. Fluorescein stain uptake was positive and extensive across the ulcerated area. The anterior chamber showed mild flare and hypopyon (approximately 1mm). Intraocular pressure (IOP) was 12 mmHg in the right eye and 8 mmHg in the left eye (normal range 10-25 mmHg). The right eye appeared clinically normal with no signs of inflammation or ulceration. Diagnostic Tests Performed: • Fluorescein staining of the left cornea • Schirmer Tear Test (STT): Right eye 18mm/min, Left eye 15mm/min (normal >15mm/min) • Tonometry (applanation): Right eye 12 mmHg, Left eye 8 mmHg • Corneal cytology (sample collected for bacterial culture and sensitivity) Diagnosis: Left eye, deep stromal corneal ulcer with descemetocele and secondary uveitis. The low intraocular pressure in the left eye is consistent with chronic inflammation and potential aqueous humour leakage or reduced production due to uveitis. Treatment Plan: • Topical Ofloxacin 0.3% ophthalmic solution: One drop to the left eye every 4 hours. • Topical Atropine 1% ophthalmic solution: One drop to the left eye twice daily. • Topical Autologous Serum: One drop to the left eye every 2 hours. • Oral Carprofen 2.2 mg/kg BID: For pain and inflammation. • Consider surgical intervention (conjunctival pedicle graft) if medical management does not show improvement within 48-72 hours or if perforation appears imminent. Risks Discussed: Potential risks of medical management include slow healing, progression to corneal perforation requiring emergency surgery, and secondary infection. Risks of surgical intervention include anaesthetic complications, graft rejection, post-operative infection, and persistent visual impairment. The owner was informed that even with successful treatment, some corneal scarring and visual deficits may remain. Prognosis: The prognosis for preserving vision in the left eye is guarded due to the depth of the ulcer and presence of a descemetocele. With aggressive medical and potentially surgical intervention, globe salvage is likely, but good visual acuity cannot be guaranteed. Follow-up Recommendations: Re-examination is recommended in 24-48 hours to assess response to treatment and consider surgical options. Once stable, weekly re-evaluations will be necessary until the ulcer is fully healed. Long-term monitoring for recurrence or complications will be advised. Additional Comments: Buddy’s owner, Mrs. Smith, is highly committed to his care and understands the seriousness of the condition. She will be diligent with topical medication administration. Patient Images: [images attached to the record] If you have any queries about this patient or any other cases do not hesitate to contact me. Yours sincerely, Dr. Eleanor Vance, BVSc, CertVOphthal, DipECVO RCVS Recognised Specialist in Veterinary Ophthalmology