|This is Max|
There are a few diseases that I only get to see once in every blue moon. They are those elusive veterinary diseases listed in the tiny paragraphs at the end of the chapter of your text book. A veterinary student, like an ornithologist, focuses on the “common birds” learning about their specific traits knowing full well that we will see them, and therefore, we need to recognize and feel comfortable and confident in treating them, but secretly we are hoping to encounter those “less commonly seen birds.” We hope and pray that somewhere along our travels we will finally get to see that magical mysterious rare bird that lives at the end of the vet school books.
When Max walked in last Tuesday (2/18/14) I finally got the chance to log his disease in my record book.
|Max as his full on welcoming self|
|Max as he looked on his initial exam on 2/18/14.|
Max walked into the clinic with his mom and brother on a Tuesday night. A shy, smiling face, with a timid wag, but a welcome expression. He is the typical Golden Retriever, quiet, sweet, gentle, un-foreboding, and willing to meet a new friend if you are quiet, calm, and unassuming. Even with his gentle expression he sat at his parents feet almost unable to open his eyes.
For a veterinarian observation of your patient before they enter the exam room, when they are calmest and least likely to feel, or act like a patient, is the best time to gather your information. Free from the influences of their parents perception, the hidden masked epinephrine hidden clues, and the biased thoughts of the veterinarian that preceded you. Just watch without anyone knowing you are, let your eyes read the small subtle clues and remember that you can diagnose a patient about 90% of the time with just your senses and an open educated mind.
I was fairly certain of Max’s dilemma, disease, and treatment needs just by secretly watching him in the reception area.
When we entered the exam room his mom gave me Max’s history. He was a middle aged, happy, healthy boy. He had a previous eye ulcer that had healed well almost a year ago, but this morning he was quiet, panting, and squinting his eyes. He had no history of trauma, illness, or exposure to toxins that might have injured his eyes. He just sat and squinted his eyes as if the brightness of the pearly gates were shining upon him beckoning him to come home.
After a thorough exam revealed no abnormalities to any other body system I took a good long look in his eyes. When you have a patient who will not open their eyes it is usually because they are painful to do so. A few drops of a short acting anesthetic in each eye will relieve their pain for just long enough for you to be able to check the eyes. Of particular concern were; his ocular pressures because glaucoma (increase in intra-ocular, or inside the globe of your eye) can be very painful and present with a patient who squints because when your eye hurts you keep it closed. These were checked with the Tonopen (a device to check the pressures in the eye) and were normal after checking both eyes several times. I was also concerned about damage to the corneas (normal on examination) and the appearance of the sclera which can indicate blood pressure and disease. Max’s eye exam was quick. He was very reluctant to be a patient eye patient and I had to gather the information I needed quickly. It took four people to hold Max, his head, and each eye open. When you need excessive force there is something wrong and you need to re-think both your strategy and your end goal. Excessive force will lead you to a bigger problem then you started with. We needed four people to keep an eye open for about four minutes. The results were more normal than abnormal but there was no denying a painful, irritated eye, and a tiny hint of “flare” in the anterior chamber.
|My poor puppy Jekyll, always the one who has to be the demo dog.|
Jekyll demonstrating the Tonopen use.
Such a good boy!
“Flare” is seen when tiny pieces of protein float inside the eye. The eye is separated into a front (anterior) and back (posterior) chamber by the lens. It can be seen with a slit lamp that sends a narrow beam of light into the anterior chamber. A normal anterior chamber is clear and allows the light to pass clearly and smoothly to the lens. When there is abnormal stuff in the anterior chamber the light gets murky and irregular.
So, Max had a diagnosis. Max had uveitis, or inflammation of the anterior chamber. I presumed the rest of his diagnosis. He is my elusive (third case in ten years) Golden Retriever Uveitis.
Lesson Learned; Always go immediately to your vet if your dog or cat is squinting. Squinting indicates pain! Eye problems can become huge disasters that could jeopardize your pets vision very quickly. But, the flip side is that in many cases eye problems can be cured very quickly too, ONCE the problem is DIAGNOSED AND a TREATMENT PLAN is started.
This is Max at his follow up appointment on February 23, 2014
Golden Retrievers can get a specific type of uveitis called "pigmentary uveitis." In this disease Golden Retrievers disperse pigment in their anterior chamber.
|Cross section of the eye|
"The iris becomes darker and thickened and clumps of pigment can be seen on both the lens capsule and corneal endothelium (inside layer of the clear corneal covering of the eye.) Aqueous flare, posterior synechia, cataract, and glaucoma may also occur. Any relation between the presence of uveal cysts, pigmentary uveitis, and glaucoma is unproven." From Slatter's Ophthalmology Text.
I spoke to Max's mom about the treatment plan and my concerns about Max's eyes.
I put max on a topical steroid with very specific instructions to monitor his eyes very closely. I also discussed my concerns with both Max's eyes and the drug I was recommending for his treatment. I wanted her to use the lowest effective dose of the eye ointment and to begin tapering the medication as soon as possible. If she had any questions or concerns about his eyes I wanted her to stop treating them and return immediately. Steroids, whether taken orally or put in your eye are both absorbed systemically and can cause both short term and long term detrimental side effects.
Max returned five days later. His eyes were wide open, comfortable and he was smiling from ear to ear. He was clearly much more comfortable and much happier. His mom had started to taper his eye steroid and was going to remain vigilant on any future flare ups or recurrence of his eye issues.
We will monitor him closely for glaucoma, uveitis recurrence, and hope that we never see either again..I will remain ever observant for the other tiny paragraph birds in the hopes that I spy another "snowy owl" among the millions of starlings...
If you have a pet related question, or just an adorable pet photo to share you can find me on Pawbly.com, or at the clinic, Jarrettsville Vet, or even on Twitter @FreePetAdvice.