Gerty's Indolent Ulcer

Gerty on January 5, 2014

This is Gerty. She is an older spayed Boxer who came in to see me on a Sunday.

Can you appreciate the squint in her left eye? And the mucous that is being produced? 

A squinting eye is a painful eye, and an eye that is producing green/yellow thick mucous is an eye that is sending massive numbers of white blood cells to it to try to beat off some villain or disease. If your pet ever looks like this it is time to see your vet. 

My first thought when I see one of these guys is that they have a defect on their cornea. We have all gotten an eyelash in our eye, and we all know how uncomfortable that can be. Some of us have even had the misfortune of getting a scratch on our cornea and know first hand that it is immensely painful! 

Your cornea is the clear covering of the globe of your eye. It is soft, flexible, and incredibly beautifully organized to repel water and yet stay clear enough to see through. It is made even more elegant by the constant necessity to be kept moist by an endless showering of tears that your eyelids distribute over it. Think of it like the windshield on your car. Can you imagine using your windshield wipers to clean your windshield without wiper fluid or rain?

We have all had a rock fly up on our windshield and chip the outer glass when we are driving. Well that sort of scenario can also happen to your cornea. If you get a piece of... well, almost anything/something in your eye, Or, if you are blinking without tears (wiper fluid), Or, if you are older and more susceptible to disease and damage, your cornea can can ulcerate (think of that chip in your windshield) and it will cause not only pain (squinting), but also excessive tearing that leads to white blood cell recruitment (mucoid ocular discharge) and a subsequent visit to see me.

The needed tools for a fluorescein test.

On physical examination an ulcerated cornea looks a little cloudy/milky, or blueish. Sometimes there are even small blood vessels that can be seen crawling down from the sclera (white part of the eye) to try to deliver more healing powers to the wound. But, to the naked eye a cornea can be hard to see. It is also difficult to see the borders of the ulcer. To help with this we use a fluorescent dye to highlight the ulcer. The dye will stick to the area of the eye that has a wound. 

After the stain is applied we use a black light to clearly see the extent of the damage. The fluorescein stain allows us to see;

1. How big the ulcer is, and,
2. How deep the ulcer is.

The whole family gets involved in this diagnostic test.
It helps my clients understand the ulcer and helps build compliance to come back for re-checks,
and it is just plain, super cool and fun!

A little messy at first.

Can you see Gerty's ulcer?
(Hint, it is from 5 o'clock to 9 o'clock on her eye.)

The medications I sent Gerty home on.
A lubricant and an antibiotic.
I also sent her home with an e-collar, because we all want to rub a painful eye,
BUT this will ALWAYS make things worse!

Gerty came back four days later for a re-check. The eye was very gradually improving, so we continued the course of her treatment. Usually ulcers need about a week or two to heal.

Every eye ulcer that I see is given written take home instructions and told to 
"call me immediately if the eye worsens!"
I also schedule a re-check in 3-5 days.
These are vital,,eyes get better FAST, and can worsen just as fast.
Those ulcers can eat through the cornea and cause the eye to rupture!

LESSON LEARNED:
Understand what an ulcer is, what treatment options are needed and when you should come back.
AND, if you think things are not getting better (in a few days) OR if you ever think that the eye is worsening RETURN ASAP!

Gerty returned again on January 25th. Unfortunately, this time the ulcer looked more like an old chronic non-healing ulcer. So, it was time for a new strategy! We switched to  stronger antibiotic and discussed referral to an ophthalmologist, surgery, running additional diagnostics and the long term consequences to vision if we couldn't diagnose and treat her eye.

Still squinting

Conjunctiva is red (red = angry).

And even without the stain you can see the cloudy ulcer is still there.

We talked about referring Gerty at this point because I was concerned about the chronicity, severity, and possible underlying causes that would be influencing the eye and making it reluctant to heal. After a long discussion we decided to try a last treatment option.

On February 4, 2014, Gerty returned for a grid keratotomy for her indolent ulcer.

A few drops of a topical ophthalmic anesthetic.
A numb eye is a happy eye!

A few minutes to let the anesthetic numb the eye, but already it feels better!

The ulcer has deposited a thick layer of non adherent cells on the defect..but the ulcer is not healing.

An indolent ulcer results when the newly recruited army of cells that are sent to the wound fail to adhere to the ulcer. It causes a sheet of cells in the ulcerated area, but unfortunately they just fail to stick to and stay put where they are needed. The ulcers, if left untreated, allow bacteria to pool and proliferate, this further prevents the ulcer from being able to heal. A long standing, untreated ulcer can lead to such significant edema (cloudiness) and scarring of the once soft flexible cornea, that it can become impossible to see through. Think of it like a blanket, or a foot of snow, on your windshield.

A cotton swab is used to remove the dead layer of non functional corneal cells.
If they didn't do their job it's time to remove them and let a new group of warriors try.

For some crazy reason, (truly, I don't know why?), Boxer's are predisposed to indolent ulcers. The treatment for these non-functional, incorrect healing ulcers is to remove the non-adherent sheet of cells, and the the eye a chance for  "do-over."

I applied a few drops of an anesthetic, waited a few minutes for it to work, and then just apply a cotton swab to...

..peel off the layer of cells.

The next part of the procedure is to give a fresh bed of "ready to stick to it" tissue. This is called a grid keratotomy. The procedure involves using a small needle to scratch the surface across and beyond the borders of the ulcer. This cross-hatching pattern allows a path for the cells to follow as they migrate in and try to again heal the wound.

Gerty went home again with an e-collar and antibiotics. She returned a few days later for her re-check. Most dogs that undergo a grid keratotomy heal within 7 days.

Re-Check appointment Sunday February 16, 2014

No squinting, and no redness!

A happy healthy girl with two normal happy healthy eyes!

Special Thanks to Gerty's family for letting me use her photo's her story and for alllll of those many re-checks..and to Gerty for always being such a patient good girl with alll of those re-checks!

If you have a pet question of any kind, or if you have a pet photo, experience, or just want to meet other pet enthusiasts you can find us at Pawbly.com, or share pet stuff with me on Twitter @FreePetAdvice. Or I'm at the clinic, Jarrettsville Vet. 

Related stories: 

Anatomy of the Eye

The Eye, Timing Matters

Golden Retriever Uveitis

Eyelid Masses, Surgery

Enucleation Surgery

Cherry Eye Surgery

Wren, the apple of my eye,
whose eyes aren't perfect either..
but, that's another story for another day.

The Eye, It's Like a Beach Ball and an Ice Cream Sandwich

Oriole's perfect eye, clear, bright, no discharge, no squinting,  and  reflecting light beautifully.

There are a few more sensitive organs in the body than the eye. Have you ever gotten an eyelash stuck in your eye? Or a bug? Or even a scratch?

Here are some the signs of a painful eye.

1.     Squinting. We call it blepharospasm.

2.     Tearing. We call it epiphora.

3.     Discharge of any abnormal amount, consistency, or color.

4.     Rubbing. Whether that is in the form of your pet rubbing their eye with their paw, or rubbing their face on the ground.

 If you have ever scratched your eye then you know how painful it is. Your eye waters, it stings, and you don’t want to open it, so what do we do? we rub it, (although we should NEVER rub!). This can further damage the cornea, and make it more difficult to heal.

There are a few very important things for you to know about your pets eyes. I’m going to give you the simple eyeball primer, but even if you forget everything else I’m going to tell you, please just remember this one thing:

Many eye problems can be fixed quickly, easily, and inexpensively IF YOU GET HELP EARLY. Eye’s can get bad quickly BUT they can also get better quickly.

This is Dusty the dachshund. Note the grey/blue cloudy look to his eye.

Here is the patient I saw last week. Note that his eye looks "cloudy." A cloudy cornea is a swollen cornea.

Here’s a simplified anatomy lesson of the cornea of the eye.

The cornea is the thin transparent tissue that forms the globe of your eye. Think of the eye like a beach ball. The cornea is the thing that you touch when you hold the ball. If you cut a piece of the beach ball, for instance if you cut a small piece of the ball and looked at it in cross section under a microscope, it looks like an ice cream sandwich. The outside cookie part of the ice cream sandwich is the epithelium, it is made up of cells that are hydrophobic. A hydrophobic cell (think phobia = fear) repels water, that way when your cry the tears roll off of your cornea. We all naturally produce tears to lubricate our eye. It is our own little internal windshield washer and wiper system.

(What would happen if you didn't produce any tears? Think of running your car’s windshield wipers running without windshield wiper fluid or rain. This is called KCS, I will talk about it soon).

If you get a scratch on the top layer of your cookie sandwich it exposes the middle layer (the ice cream) called the stroma. The stroma is hydrophilic, it loves water. When the stroma is exposed to water (think tears) it gets sucked into the stroma causing it to swell. This causes the cornea to get cloudy.

When we see a patient come in with a cloudy cornea we use a special stain, called flourescein. If there is a tear in the outer (epithelium) cookie layer the flourescein will bind to the stroma and glow a bright green under a black light. The fluorescein helps us to identify how deep and how large the damage is. 

Dusty's eye takes up the fluorescein in a smal rectangular area just above the fingertip of his owner. The fluorescein also lines the edges of the eye. Sometimes it will even drip out of the nose.

Most acute (new/recent) corneal traumas are ulcers. An ulcer is classified as either an uncomplicated or indolent (meaning it is chronic and not healing).

An uncomplicated ulcer should be treated immediately. They should heal in about 3-5 days.

The patient that I saw the other day had been squinting for about 5 days. (Yes, I gave a small lecture about getting treatment for eyes ASAP!). Dusty, the dachshund was squinting and there was thick yellow discharge from his eye.

After his stain test was positive we put him on an ophthalmic antibiotic, eye drops for pain, and an e-collar so he couldn't rub the eye anymore. I also had Dusty’s owner bring him back in 3 days for a re-check.

Three days later Dusty’s eye looked great! The e-collar came off, the pain medicine stopped and he was well on his way to healing.

OK, here’s the rest of the important eye information.

1.     If the eye ever looks worse STOP using the medicine and get back to the vet ASAP.

2.     If the eye isn’t better in 3-5 days, get back to the vet ASAP.

3.     If your pet gets other clinical signs like sneezing, coughing, vomiting, not eating, excessive drinking, or any worsening of the eye get to the vet ASAP.

One more note any pet that has had more than two incidents of ulcers should have a thorough ophthalmic examination and be monitored very closely. Many pets are predisposed to recurrent ulcers due to an underlying ocular abnormality. Just like all of the rest of the tissue in our body, every time it is damaged it heals with a scar. Eventually your transparent cornea scars and it is like trying to look at the world through scratched thick eyeglasses that you just can't every get clean or clear again.