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Making the diagnosis of a corneal ulcer is critical for the welfare of the patient. It is the difference between sight and blindness, or a small scar and a large scar. Assume ulcers will get worse! Treat aggressively.
The dog cornea is 0.55 mm thick centrally and 0.65 mm thick peripherally. The cat cornea is about 0.58 mm thick centrally and peripherally. The superficial cornea is most sensitive. The tear film gives a smooth optical surface. Most of the stroma is collagen. The endothelium contains a pump.
Nerves
Corneal epithelium is a barrier against bacteria. In simple traumatic corneal injuries in which a small amount of epithelium is removed, healing is rapid.
If the ulcer becomes infected or the epithelium is unable to attach to the stroma, healing is delayed, and progression to a deep stromal ulcer may occur. WBCs can help too much!! NE and MMPs.
In infected ulcers, tear proteases digest stromal collagen to cause a descemetocele, and iris prolapse (within 24 hrs). Proteases (MMP and NE) are produced by keratocytes, tear film PMNs and microbes.
Melting
??
Corneal degeneration due to proteases is referred to as "melting". Ulcers in which proteases are active have a grayish-gelatinous appearance Distinguish melting from corneal edema. Topical corticosteroids increase tear protease activity. MMP-9 increased in dog ulcers
A corneal ulcer is a lesion in which the corneal epithelium and a variable amount of corneal stroma have been lost. Cobalt blue filters aid diagnosis.
Regardless of the initial cause, all ulcers are associated with some iridocyclitis. The uveitis may be severe with the potential to progress to endophthalmitis.
Hypopyon
Trauma Foreign bodies Exposure (anesthesia, CN7 paralysis) Entropion and trichiasis Eyelash disease- distichiasis, ectopic cilia Boxer ulcers and nonadherence
B. Infectious: Bacterial, Mycotic, Viral C. KCS D. Bullous Keratopathy - Cats E. Neurotrophic corneal insensitivity F. Neuroparalytic - CN7 paralysis
Diagnosis of Corneal Ulceration a. Clinical signs of ulceration: 1) Pain and blepharospasm 2) Tearing 3) Purulent ocular discharge 4) Miosis due to uveitis 5) Corneal edema/vascularization
The primary objective of current treatment strategies for infectious keratitis is to sterilize the ulcer as rapidly as possible with topically administered antibiotics.
Kill everything !!
Ulcers can degenerate even if sterile! Sterility does not guarantee healing!!
Treat etiology: eg KCS, entropion, infection Broad-spectrum topical antibiotics culture and sensitivity tests can guide selection. Reduce tear protease activity: EDTA, Serum, Acetylcysteine Serum contains an alpha-2 macroglobulin with anticollagenase activity. Treat Uveitis Topical atropine: cycloplegia/mydriasis Topical NSAIDs?????
Horses: Increasing resistance of Streptococcus to gentamicin, and Pseudomonas to gentamicin and tobramycin.
Pseudomonas: 20% resistant to gentamicin and tobramycin in 92-98 and 55% resistant at present. Ciloxan is still good for Pseudomonas.
RB positive
Antiproteases
Inhibition of MMP-2 & MMP-9 is most important in dogs, cats and horses The significance of the serine proteases is under investigation Serum
2-macroglobulin = protease inhibitor that entraps both main classes of proteases 1-PI (serine protease inhibitor )
Combining antibiotic therapy with MMP inhibitors can speed corneal healing as MMP play an important role in corneal ulceration and stromal liquefaction.
Fibrin
Hypopyon
Superficial Ulcers with Minimal Corneal Tissue Loss Triple antibiotic or tobramycin QID 1% atropine SID or BID till pupil is dilated- May not send home. Serum QID recheck the next day to evaluate for melting
Eyes with ulcers should show reduced fluorescein uptake and the eye be less painful in 24-48 hours, unless...
Melting ulcers should show an increase in stromal rigidity in the first 24 hours. If not, surgery is indicated as corneal rupture is possible.
Healing of a corneal ulcer will be observed as a 360 clearing of the cornea, beginning at the limbus. If the cornea is healing, the stimulus for the uveitis should be reduced
the pupil will stay dilated easier The frequency of atropine therapy can be reduced.
PMNs are stimulated by epithelial cell cytokines to release serine and matrix metalloproteases to cause melting.
Topical Serum is very beneficial for melting ulcers. It inhibits serine proteases and MMPs. Topical EDTA (0.17%) and acetylcysteine (5%) inhibit MMPs. Ilomostat Topical 0.1% doxycycline
Combined antibiotic/protease inhibitor therapy might improve clinical results. Ulceration often continues due to the continued presence of tear proteases in spite of ulcer sterilization with effective antibiotic treatment.
Conjunctival flap autografts are used for the clinical management of: deep and large corneal ulcers stromal abscesses descemetoceles perforated corneal ulcers with and without iris prolapse.
Tarsorrhaphies and TE flaps
CF surgery requires general anesthesia. Pedicle flaps allow monitoring of the anterior chamber
Leave in place for 4-6 wks. Most CFs require a temporary tarsorrhaphy.
Conjunctival flap/Tarsorrhaphy
DESCEMETOCELES
14 microns!!
??
2
Dixie Stacy
Iris Prolapse
a) Emergency b) Systemic antibiotics c) General anesthesia and surgical repair of cornea d) Topical antibiotic solutions, not ointments. Topical atropine e) Reposition or amputate protruding iris; suture cornea (7-0 suture); reform AC with LRS f) CF if needed
CORNEAL LACERATIONS
Management depends on depth of laceration. Superficial lacerations (stain with FL). Treat as simple ulcer topical antibiotics and atropine Deep, non-perforating lacerations. Topical antibiotics, serum and atropine Less than 1/2 thickness: CF or treat as ulcer More than 1/2 thickness: suture cornea
Herpes keratitis
Cats Dendritic ulcers of the cornea and conjunctiva
Topical acyclovir or idoxuridine QID Oral lysine 500 mg BID Viralys Vet Oral interferon: 300 U/day
Clinical Signs:
Superficial corneal erosion with epithelial "lips" (Epithelium rolled up and back at edges) Chronic blepharospasm, epiphora, and photophobia Lesions usually unilateral Fluorescein diffuses under epithelium
The cause is a defect in the hemidesmosomes of the basal corneal epithelial cells. The basal corneal epithelium may not be producing normal basement membrane. A hyaline membrane forms on the ulcer.
Ectopic Cilia
Remove abnormal epithelium by debridement with topical anesthesia and cotton-tipped applicator may need numerous debridements
the lip
Scratchers
Grid Keratotomy for superficial ulcers only! 20 gauge needle. Not for cats!!
scars
Use Elizabethan collars to help prevent self trauma Adequan (100 mg/ml) for topical use:
50 mg/ml in PVA artificial tears (Tears Naturale)
Growth factors in serum may be beneficial in persistent erosions. EGF?? Hylashield (Hylan) topically Soft contacts and collagen shields Chemical cautery (Lugols iodide, TCA, phenol) Superficial keratectomy Tarsorrhaphies and TE Flaps
FB Day 7 Day 1