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.

Golden Retriever Uveitis, Max's Rare Bird.

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.

Related articles;

The Eye, Timing Matters.

Eyelid Masses, Surgery To Remove Them.

Crying Blood, Enucleation Surgery

Cherry Eye Surgery

Anatomy of the Eye, It's Like a Beach Ball and an Ice Cream Sandwich