Initial Appointment Referral Letter

1 November 2024 Client Details Ms. Jane Doe 123 Veterinary Lane Animal Town VT1 2ER Patient Details Name: Buddy Age: 8 years Sex: Male, neutered Species: Canine Breed: Labrador Retriever History BIOP: 7 years Other pets: One feline, 'Whiskers', 5 years old, indoor only, no known health issues. Vaccinations/Flea/Worming: Up to date Diet: Hill's Science Diet Adult Large Breed, fed twice daily. Known food allergies: No Travel history: Annual trips to the Scottish Highlands. Other conditions: Mild hip dysplasia managed with NSAIDs as needed. General health: Buddy has generally been in good health, aside from occasional lameness related to his hip dysplasia. Over the past three weeks, his owner has noted him rubbing his left eye frequently and experiencing increased tearing. He appears to be more sensitive to light and has been less enthusiastic about his daily walks. Previous ocular conditions/surgeries: No Eye history: Three weeks ago, Buddy developed a sudden onset of left eye redness and excessive tearing. The owner initially thought it was an allergy but symptoms have progressively worsened, including squinting and avoidance of bright lights. He has been rubbing the eye with his paw, leading to mild periocular irritation. There has been no visible discharge or change in general behaviour apart from being slightly subdued. Current medications: Carprofen 25mg orally BID PRN for hip pain. Previous medication reactions: No Ophthalmic Examination Distant Examination Ocular OD: NAD Ocular OS: Moderate blepharospasm, epiphora. Periocular OD: NAD Periocular OS: Mild erythema and moist dermatitis ventrolateral to the left eye. 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: 18 STT (mm/min) OS: 8 Tear film quality OD: Good Tear film quality OS: Good IOP (mmHg) OD: 15 IOP (mmHg) OS: 18 Neuro-Ophthalmic Examination PLR OD: Positive PLR OS: Positive Consensual PLR OD: Positive Consensual PLR OS: 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: Mild swelling of upper and lower eyelids. Lacrimal punctae OD: NAD Lacrimal punctae OS: Patent Palpebral conjunctiva OD: NAD Palpebral conjunctiva OS: Hyperaemic, mild follicular proliferation. Bulbar conjunctiva OD: NAD Bulbar conjunctiva OS: Diffuse hyperaemia, chemosis. Third eyelid OD: NAD Third eyelid OS: Prominent, mild oedema. Cornea OD: NAD Cornea OS: Diffuse corneal oedema, central superficial ulcer 2mm in diameter, positive fluorescein uptake. Sclera OD: NAD Sclera OS: NAD Anterior chamber OD: NAD Anterior chamber OS: Mild flare, no hyphema or hypopyon. Iris OD: NAD Iris OS: Mild miosis. Iridocorneal angle OD: NAD Iridocorneal angle OS: NAD Lens OD: NAD Lens OS: NAD 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: Positive, corneal ulcer present. Jones test OD: Positive Jones test OS: Positive Ultrasound OD: No significant findings. Ultrasound OS: No significant findings. Obstacle Course: Photopic (light) conditions: Navigated obstacle course well. Scotopic (dark) conditions: Navigated obstacle course well. Laboratory Diagnostics: Complete Blood Count: WNL. Serum Biochemistry: WNL. General Physical Examination: Demeanour: Bright, alert, responsive. MM: Pink, moist. CRT: <2 seconds. Thoracic auscultation: Clear lung sounds, no murmurs. Abdominal palpation: Soft, non-painful. Lymph nodes: Palpable and symmetrical, normal size. Clinical Photographs Clinical photographs taken of Buddy's left eye, showing blepharospasm, epiphora, and corneal oedema prior to fluorescein staining. Diagnosis OS: Keratoconjunctivitis Sicca (KCS) OS: Corneal ulcer, superficial OS: Anterior uveitis secondary to corneal ulcer Recommended Diagnostic Plan * Schirmer Tear Test (STT) recheck in 7 days. * Corneal cytology and culture if ulcer not responding to treatment. * Further investigation for underlying causes of KCS if needed. Treatment Plan * Optimune (Cyclosporine) ointment 0.2% OS BID * Remend (Hyaluronic acid) eye drops OS TID * Atropine 1% eye drops OS SID (until pupil dilation achieved) * Tobramycin ophthalmic solution OS TID * Elizabethan collar to prevent self-trauma. Summary Buddy, an 8-year-old neutered male Labrador Retriever, was referred for progressive left eye discomfort, redness, and epiphora over three weeks. Ophthalmic examination revealed severe keratoconjunctivitis sicca (STT 8 mm/min OS), a superficial corneal ulcer with oedema OS, and secondary anterior uveitis. His general health is good, with well-controlled hip dysplasia. The diagnostic plan includes monitoring STT and ulcer healing, with further diagnostics if needed. Treatment focuses on improving tear production, supporting corneal healing, and managing inflammation and infection. Next Follow-Up Examination 8 November 2024 Thank you for referring this case, it was a pleasure looking after Buddy. Please feel free to contact me by phone or email in case of any questions. Our contact telephone number is 020 7946 0958, alternatively you can email info@examplevetreferral.com. Dr. Sarah Miller, DVM, MRCVS RCVS Advanced Practitioner in Veterinary Ophthalmology Senior Ophthalmologist Supervised by: Professor David Lee, BVSc, PhD, DipACVO, FRCVS Head of Ophthalmology