cornea diagnostic tests for corneal epithelium 7 superficial corneal ulcer n generally extremely...

Download Cornea Diagnostic tests for corneal Epithelium 7 Superficial Corneal Ulcer n Generally extremely painful

Post on 12-Jul-2020

0 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • 1

    The Cornea: 0.5mm is all you get

    David A. Wilkie DVM, MS, Diplomate ACVO Professor Emeritus

    The Ohio State University Wilkie.1@osu.edu

    0.5-0.6 mm

    Cornea Epithelium n 8-15 cell layers thick

    7 day turnover

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

    n Culture n Schirmer tear test n Fluorescein dye n Cytology

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

  • 2

    Getting Old?

    You have many choices in loupes

    Loupes

    You get what you pay for

    Recommend: Zeiss - $$$ Keeler Heine

    Bad Choice

    Good Choice

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

    n Culture

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

    n Culture n Cytology

    www.microbrush.com

  • 3

    Cytology and Culture

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

    n Culture n Schirmer tear test

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

    n Culture n Schirmer tear test n Fluorescein dye

    Tear Break-up

  • 4

    Tear Break-up - Human Abnormal Tear Break-up - Canine

    Diagnostic tests for corneal abnormalities

    n Examination n Finoff n Biomicroscopy

    n Culture n Schirmer tear test n Fluorescein dye n Cytology n Biopsy and histopathology

    Corneal SCC

    Ulcerative Keratitis n Most ulcers are simple and heal in 24-72

    hours, often DESPITE what the Veterinarian does

    n When they fail to do so: n Did I miss the etiology? n Is it infected? n Have I done a culture/cytology? n What drugs are being used? n Is it time to discuss surgery?

    Ulcerative Keratitis n Ascertain the etiology of the lesion.

    WHY?

    Ulcerative Keratitis n Ascertain the etiology of the lesion. n Examine the eye for:

    n eyelid abnormality

    Entropion

  • 5

    Ulcerative Keratitis n Ascertain the etiology of the lesion. n Examine the eye for:

    n eyelid abnormality

    Trichiasis

    Ulcerative Keratitis n Ascertain the etiology of the lesion. n Examine the eye for:

    n eyelid abnormality n abherent hair

    Ectopic cilia

    Ectopic cilia

    Ulcerative Keratitis n Ascertain the etiology of the lesion. n Examine the eye for:

    n eyelid abnormality n abherent hair n foreign body

    Corneal foreign body penetrating vs perforating

  • 6

    Ulcerative Keratitis n Ascertain the etiology of the lesion. n Examine the eye for:

    n eyelid abnormality n abherent hair n foreign body n tear deficiency n infectious causes

    Ulcerative Keratitis n Complete history

    n duration n previous therapy (especially corticosteroids)

    Ulcer

    Erosion Superficial

    Midstromal

    Deep

    Descemetocoele

    Superficial Corneal Ulcer

  • 7

    Superficial Corneal Ulcer n Generally extremely painful n Heal within 72 hours when the cause has

    been removed n If the ulcer has not resolved in 3 to 5 days:

    n cause is still present n ulcer is infected n indolent ulcer is present

    Indolent Ulcer

    Failure of attachment

    Indolent Ulcer n Hallmark features:

    n Superficial n Nonpainful to mildly painful n Loose or redundent epithelial borders n Usually middle aged to older dogs n Chronic in nature n Predisposed breeds - boxers

    Indolent Ulcer

    Indolent Ulcer Debride

  • 8

    Debride Grid Keratotomy

    Debride

    Grid Keratotomy

    n Algerbrush diamond burr

    3.5mm, medium grit tip

    Diamond Burr Debridement

    Courtesy Dr Enry Garcia, University of Colorado https://www.youtube.com/watch?v=W 2ndvDx_1SE

    Algerbrush; Alger Equipment Company, Lago Vista, TX, USA

    n Outcome n Debridement - 63% healed after single

    procedure n 25% healed at 1st postop visit

    n GK - 85% healed after single procedure n 75% healed at 1st postop visit

    n SK – 100% healed after single procedure n 88% healed at 1st postop visit

    https://www.youtube.com/watch?v=W2ndvDx_1SE

  • 9

    Indolent Ulcer

    n Treatment: n Client education is essential n Remove loose, redundant epithelium n Gently break the basement membrane with

    25g needle (Grid keratotomy) n Diamond burr n Topical tetracycline - 50% reduced time to

    heal (oral doxy also works) n Recheck every 7-14 days

    Indolent Ulcer n Treatment:

    n Contact lens: n 15mm diameter, thin,

    soft bandage lens n >8mm base curve n Acrivet

    n Antibiotics

    Adult cat - herpes n classic dendritic

    ulcer n no URT signs

    Herpes felis n 70% of cats infected with herpes virus

    will become carriers n recurrent conjunctivitis/keratitis n stress and immunosuppression will

    predispose to recurrence n FeLV n FIV n Other

  • 10

    Herpes felis n Diagnosis:

    n History - previous stress?

    Herpes felis n Treatment:

    n Antiviral agents topically nIdoxuridine - Stoxil, Herplex nTrifluorothymidine - Viroptic nq2-4 hr

    n Cidofovir 0.5% nQ12 hr

    Herpes felis n Treatment

    n Antivirals - Systemic n Famciclovir

    n Variable doses listed n 65 mg/cat divided daily n New data suggests 40 mg/kg PO n 90 mg/kg PO TID

    Herpes felis n Treatment:

    n L-lysine, 250-500 mg/day PO

    Midstromal Corneal Ulcer n Managed medically n Associated anterior uveitis n Cytology n Culture/Sensitivity

    Midstromal Corneal Ulcer n Treatment:

    n Topical antibiotics nBroad spectrum, every 2-6 hours nNeomycin-bacitracin-polymyxin nGentamicin -poor choice nCiprofloxacin nLevofloxacin nGatifloxacin

  • 11

    Midstromal Corneal Ulcer n Treatment:

    n 1% Atropine nas needed to dilate the pupil, but

    not more than 4x/day

    XX

    Midstromal Corneal Ulcer n Treatment:

    n Surgery if progressive n Desmetocoele n Melting/collagenase ulcer n Acute eruptive keratopathy

    n feline

    Deep/Desmetocele Corneal Ulcer

    n Fluorescein negative centrally

    Melting Corneal Ulcer n Enzymatic

    breakdown of the cornea

  • 12

    Melting Corneal Ulcer n Surgery often indicated n Debridement of the melting portion

    Melting Corneal Ulcer n Treatment:

    n As for deep ulcers, but more aggressive

    n Antibiotics are administered every 1-2 hours n Ofloxacin n Levofloxacin n Gatifloxacin

    n Anticollagense n Serum n Tetracycline - topical, systemic

    n +/- Surgery

    Corneal Cross-linking

    Riboflavin-photosensitizer

    UV-A

    Corneal cross-linking

    Specialized instruments

    Corneal Surgery

    Superficial Keratectomy n Thickness of the normal canine cornea is 0.4-

    0.7mm n #64 Beaver blade/Desmarres corneal

    dissector

    Superficial Keratectomy

  • 13

    Superficial Keratectomy

    Lamellar dissection

    Superficial Keratectomy

    0.12mm Colibri

    Avoid tension in this direction

    Superficial Keratectomy

    http://youtu.be/vB0P3lJmvXU

    Graft? Yes or No Feline Sequestrum Keratectomy

    https://www.youtube.com/watch?v=JjHx6-TR8d0

    http://youtu.be/vB0P3lJmvXU https://www.youtube.com/watch?v=JjHx6-TR8d0

  • 14

    While on the subject of brown corneas..

    Vitreous echo-hemorrhage

    Posterior scleral rupture

    Normal

    Preop 5 days

    15 days 60 days 300 days

  • 15

    Canine Corneal SCC SCC pre surgery

    SCC post surgery plus 5-FU

    SCC beta radiation

    Conjunctival Pedicle Graft

    Dissect dorso-lateral conjunctiva

    Conjunctival Pedicle Graft

    Keratectomy prepares site

    Conjunctival Pedicle Graft

    Epithelial to epithelial apposition

  • 16

    Conjunctival Pedicle Graft

    http://youtu.be/qC2Amv5RW-k

    Conjunctival Pedicle Graft

    http://youtu.be/IRzC3lHRdps

    Equine conjunctival pedicle graft -trimming Equine conjunctival pedicle graft -trimming

    http://youtu.be/qC2Amv5RW-k http://youtu.be/IRzC3lHRdps

  • 17

    Corneal Perforation

    Iris prolapse

    Corneal-Conjunctival Graft

    Corneal-Conjunctival Graft

    http://youtu.be/NvwnZhGpK6M

    Feline corneo-conjunctival graft

    1 yr post-op

    24 hr post-op

    Canine corneo-conjunctival graft Corneal endothelial dystrophy

    Treatment -hyperosmotics -conj graft -fresh transplant

    http://youtu.be/NvwnZhGpK6M

  • 18

    Pre-op

    Post-op

    Keratectomy with BioSiSt® Graft

    Keratectomy with BioSiSt® Graft

    Keratectomy with BioSiSt® Graft

  • 19

    Deep lamellar endothelial keratoplasty Deep Lamellar Keratectomy

    Deep Lamellar Keratectomy Deep Lamellar Keratectomy

  • 20

    Corneal Transplant

    Corneal transplant

    Corneal transplant

    Corneal transplant Corneal transplant

  • 21

    Corneal transplant

    Penetrating Keratoplasty

    Penetrating Keratoplasty Penetrating Keratoplas

Recommended

View more >