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, Male Neutered Date of Examination: 1 November 2024 Reason for Referral: Buddy was referred due to a persistent left eye discharge and apparent discomfort that has been progressing over the last three weeks. The referring veterinarian noted a cloudy appearance to the cornea and suspected an underlying corneal pathology requiring specialist assessment. History: Buddy has a history of seasonal allergies managed with over-the-counter antihistamines. Approximately three weeks ago, his owner noticed increased lacrimation and a thick, yellowish discharge from the left eye. Initial treatment with topical antibiotic drops (fusidic acid) for one week provided no significant improvement. The owner also reports Buddy frequently rubs his left eye against furniture. There is no known history of trauma to the eye. No other systemic signs of illness have been observed. 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 the right eye, but sluggish and incomplete in the left. External examination of the left eye showed significant epiphora, blepharospasm, and mild conjunctival hyperemia. The third eyelid was slightly prolapsed. Slit-lamp biomicroscopy revealed a central corneal ulcer approximately 4mm in diameter with marked corneal oedema and neovascularisation extending from the limbus. A positive fluorescein stain was observed. Intraocular pressure (IOP) measured 18 mmHg in the right eye and 12 mmHg in the left eye. The right eye examination was unremarkable. Diagnostic Tests Performed: - Fluorescein Stain Test (left eye, positive) - Schirmer Tear Test (right eye: 18 mm/min, left eye: 7 mm/min) - Tonometry (right eye: 18 mmHg, left eye: 12 mmHg) - Corneal Cytology (left eye, revealed neutrophils and coccoid bacteria) Diagnosis: Primary diagnosis: Deep, infected corneal ulcer of the left eye with secondary keratomalacia and reflex uveitis. Differential diagnoses included a foreign body, indolent ulcer, or fungal keratitis. Treatment Plan: - Topical Ciprofloxacin 0.3% ophthalmic solution: Apply one drop to the left eye every 4 hours for 7 days. - Topical Atropine 1% ophthalmic solution: Apply one drop to the left eye twice daily for 3 days to manage reflex uveitis and discomfort. - Oral Carprofen 2.2 mg/kg: Administer twice daily with food for 5 days for pain management and anti-inflammatory effects. - E-collar: To be worn continuously to prevent self-traumatisation. Prognosis: The prognosis for visual recovery in the left eye is guarded due to the depth and infection associated with the corneal ulcer. However, with aggressive medical management, healing is expected, though some corneal scarring leading to visual impairment is possible. Prompt and diligent adherence to the treatment plan is crucial. Follow-up Recommendations: Buddy should be re-examined by a veterinary ophthalmologist in 5-7 days to assess ulcer healing progress and adjust medication as needed. Long-term monitoring for potential complications such as glaucoma or chronic dry eye is recommended. Please contact us immediately if there is any worsening of symptoms or new concerns. Additional Comments: The low Schirmer Tear Test result in the left eye suggests a component of keratoconjunctivitis sicca (KCS) may be contributing to the chronicity or poor healing of the ulcer. This will be addressed once the acute infection and ulceration are under control. Patient Images: If you have any queries about this patient or any other cases do not hesitate to contact me. Yours sincerely, Dr. Eleanor Vance, DVM, DipACVO Board-Certified Veterinary Ophthalmologist