Recheck Appointment Referral Letter

1 November 2024 Client Details Ms. Eleanor Vance 45 Oakwood Drive Suburbia Kent KT12 3AB Patient Details Name: Bella Age: 8 years Sex: Spayed Female Species: Canine Breed: Labrador Retriever History Condition being monitored: Chronic dry eye (Keratoconjunctivitis Sicca - KCS) in both eyes, particularly the right eye. Previous appointment: At the last appointment on 15 October 2024, Bella presented with increased ocular discharge and redness in the right eye. Schirmer Tear Test (STT) values were notably low (OD: 3 mm/min, OS: 7 mm/min). Treatment was adjusted to include tacrolimus 0.03% ophthalmic ointment BID OU, alongside continued ciclosporine ophthalmic emulsion BID OU. Progress since last appointment: Bella's owner reports significant improvement in the right eye since the medication adjustment. There is less discharge and redness, and Bella appears more comfortable. The left eye remains stable with no new concerns. Current medications: * Tacrolimus 0.03% ophthalmic ointment BID OU * Ciclosporine ophthalmic emulsion BID OU Ophthalmic Examination Distant Examination Ocular OD: Mild mucoid discharge, mild conjunctival hyperaemia. Ocular OS: NAD. Periocular OD: NAD. Periocular OS: NAD. Head OD: NAD. Head OS: NAD. Visual axis OD: Clear tapetal reflex. Visual axis OS: Clear tapetal reflex. Tear Film Parameters and Intraocular Pressures STT (mm/min) OD: 10 mm/min STT (mm/min) OS: 12 mm/min Tear film quality OD: Good Tear film quality OS: Good IOP (mmHg) OD: 15 mmHg IOP (mmHg) OS: 16 mmHg Neuro-Ophthalmic Examination PLR OD: Positive PLR OS: Positive Consensual PLR OD: OD>OS: Positive Consensual PLR OS: OS>OD: Positive Chromatic PLR blue OD: Positive Chromatic PLR blue OS: Positive Chromatic PLR red OD: Positive Chromatic PLR red OS: Positive Menace OD: Positive Menace OS: Positive Dazzle OD: Positive Dazzle OS: Positive Vestibulo-ocular reflex OD: Positive Vestibulo-ocular reflex OS: Positive Corneal OD: Positive Corneal OS: Positive Palpebral OD: Positive Palpebral OS: Positive Slit Lamp Examination Eyelids OD: NAD. Eyelids OS: NAD. Lacrimal punctae OD: NAD. Lacrimal punctae OS: NAD. Palpebral conjunctiva OD: Mild hyperaemia. Palpebral conjunctiva OS: NAD. Bulbar conjunctiva OD: Mild hyperaemia. Bulbar conjunctiva OS: NAD. Third eyelid OD: NAD. Third eyelid OS: NAD. Cornea OD: Mild superficial keratitis, no ulceration. Cornea OS: NAD. Sclera OD: NAD. Sclera OS: NAD. Anterior chamber OD: NAD. Anterior chamber OS: NAD. Iris OD: NAD. Iris OS: NAD. Iridocorneal angle OD: NAD. Iridocorneal angle OS: NAD. Lens OD: Mild nuclear sclerosis. Lens OS: Mild nuclear sclerosis. Vitreous OD: NAD. Vitreous OS: NAD. Retina/optic nerve OD: NAD. Retina/optic nerve OS: NAD. Additional Ophthalmic Diagnostics Fluorescein test OD: Negative Fluorescein test OS: Negative Jones test OD: Positive Jones test OS: Positive Clinical Photographs Right eye: Image ref: Bella_OD_011124.jpg - Anterior segment of right eye, showing mild conjunctival hyperaemia. Left eye: Image ref: Bella_OS_011124.jpg - Anterior segment of left eye, unremarkable. Profile: Image ref: Bella_Profile_011124.jpg - Full facial profile. Diagnosis Bella continues to be managed for bilateral Keratoconjunctivitis Sicca (KCS), with the right eye showing chronic changes and requiring ongoing aggressive medical therapy. The recent adjustment in medication has yielded positive results, with STT values showing significant improvement. The mild superficial keratitis in the right eye is consistent with chronic dry eye but currently stable. Recommended Treatment Continue current medications: * Tacrolimus 0.03% ophthalmic ointment BID OU * Ciclosporine ophthalmic emulsion BID OU Monitor for any recurrence of discharge or discomfort. No further immediate changes are recommended given the current positive response. Summary Bella, an 8-year-old spayed female Labrador Retriever, presented for a recheck of her bilateral KCS. She has shown good progress since her last appointment, with STT values improving significantly in both eyes, particularly the right eye which had been more severely affected. Ophthalmic examination revealed mild conjunctival hyperaemia and superficial keratitis in the right eye, consistent with controlled KCS. The current therapeutic regimen appears effective, and no further adjustments are deemed necessary at this time. Prognosis remains good with continued medical management. Next Follow-Up Examination In 3 months Thank you for referring this case, it was a pleasure looking after Bella. Please feel free to contact me by phone or email in case of any questions. Our contact telephone number is 01234 567890, alternatively you can email info@vetophthalmology.com. Dr. Sarah Jenkins MRCVS RCVS Recognised Specialist in Veterinary Ophthalmology Senior Veterinary Ophthalmologist Supervised by: Professor David Lee MRCVS Diplomate ACVO, ECVO Head of Ophthalmology Department