Emergency tips

• Embedded in the superficial corneal tissue • Embedded deep into the corneal tissue For those foreign bodies that are adherent to the corneal surface or superficial, removal can be attempted with care. Foreign bodies that are embedded deep or have penetrated the cornea, or if you are not sure if they are deep or penetrated, an ophthalmologist should be called to do removal. It is common for a secondary anterior uveitis to develop as a result of a corneal foreign body (reflex anterior uveitis), however if there is hyphema present, shallow anterior chamber or anterior synechia – iris prolapse, it is likely that a full thickness penetration has occurred and an ophthalmologist should be called to If there are signs of infection or melting, the cornea should be treated as a If you are CONFIDENT that the foreign body is not deep nor has penetrated the anterior chamber, the following suggestions may be helpful: a. Apply topical proparacaine - recommend 1-2 drops every 1 minute for a total b. Patient must be sedated if not adequately still/restrained c. Attempt removal using a sterile cotton swab, Weck Cell Sponge, (cilia/jewelers/tying) forceps, or a 25- 30-gauge needle, or sharp irrigation (6 cc syringe filled with sterile eye wash and fitted with 24 gauge IV catheter) if foreign body adhered to the corneal surface. d. If successful, best to stain eye with fluorescein and record corneal defect size and depth. TGH with: E-collar, Neopolybacitracin TID in dogs; Erythromycin TID in cats, atropine 1% BID, and systemic NSAID until recheck exam in 3 – 5 days (hospitalize or recheck in 24 hours if the ulcer is complicated). Treatment in ES until referral or an in-house ophthalmologist is available. b. Ciprofloxacin Ophthalmic Solution: 1 drop every 2 hours c. Cefazolin Ophthalmic Solution (50 mg/ml): one drop every 2 hours (keep refrigerated) (when multiple eye drops are being used separate each by at least 10 minutes to avoid wash out). See Reference section. It is ok to just use ciprofloxacin drops if the pharmacy is not open. d. Atropine 1% solution one drop every 5 minutes for 3 doses (or to effect = pupil dilated), then two to three time per day. f. Systemic antibiotic (chose doxycycline if there is collagenase or melting since doxycycline is an excellent antiproteinase and gets into the tear film when given systemically). Choose other antibiotic systemically per your clinical h. DO NOT USE TOPICAL ANESTHETIC THERAPEUTICALLY – PROPARACAINE WOULD DO HARM if used therapeutically! A Descemetocele is a surgical emergency. Needs a surgical graft. Diagnosis is made by observation. Do not stain with fluorescein if it appears that a Descemetocele is present since fluorescein stings and the rapid closure of the eye could rupture the cornea. Whether fluorescein would be retained or not is a moot point with a Descemetocele since this ulcer is too deep to expect to heal with only medical therapy. Do NOT use 2. Keep animal calm as possible even if this means drugs – something with analgesia i.e.: low dose torbugesic or buprenorphine. 3. Ciprofloxacin ophthalmic solution: 1 drop every 2 hours a. Cefazolin Ophthalmic Solution (50 mg/ml): one drop every 2 hours (keep refrigerated) (when multiple eye drops are being used separate each by at least 10 minutes to avoid wash out). See Reference section. It is ok to just use ciprofloxacin drops if the pharmacy is not open. 4. Serum or plasma (EDTA) or EDTA: 1 drop every 2 hours 5. Atropine 1% solution one drop every 5 minutes for 3 doses (or to effect = pupil dilated), then two to three time per day. 7. Systemic antibiotic (chose doxycycline if there is collagenase or melting since doxycycline is an excellent antiproteinase and gets into the tear film when given systemically). Choose other antibiotic systemically per your clinical judgment. 9. DO NOT USE TOPICAL ANESTHETIC THERAPEUTICALLY – PROPARACAINE WOULD DO HARM if used therapeutically! Since this is a surgical disease, when Emergency submits the pre-anesthetic blood work, this will help the ophthalmologist a lot. Be sure to sedate the animal before taking blood or placing an IV catheter, since struggling during venapuncture or catheter placement could rupture the cornea from An iris prolapse is a surgical emergency and should not be stained with fluorescein. If the full thickness wound becomes unsealed/ruptures, the same therapy is used as for Surgery must be arranged as soon as possible. 2. Keep animal calm as possible even if this means drugs – something with analgesia i.e.: low dose torbugesic or buprenorphine. 3. Ciprofloxacin ophthalmic solution: 1 drop every 2 hours a. Cefazolin Ophthalmic Solution (50 mg/ml): one drop every 2 hours (keep refrigerated) (when multiple eye drops are being used separate each by at least 10 minutes to avoid wash out). See Reference section. It is ok to just use ciprofloxacin drops if the pharmacy is not open. 4. Serum or plasma (EDTA) or EDTA: 1 drop every 2 hours 5. Atropine 1% solution one drop every 5 minutes for 3 doses (or to effect = pupil dilated), then two to three time per day. 7. Systemic antibiotic (chose doxycycline if there is collagenase or melting since doxycycline is an excellent antiproteinase and gets into the tear film when given systemically). Choose other antibiotic systemically per your clinical judgment. 9. DO NOT USE TOPICAL ANESTHETIC THERAPEUTICALLY – PROPARACAINE WOULD DO HARM if used therapeutically! Since this is a surgical disease, when Emergency submits the pre-anesthetic blood work, this will help the ophthalmologist a lot. Be sure to sedate the animal before taking blood or placing an IV catheter, since struggling during venapuncture or catheter placement could rupture the cornea from Try to determine if Exogenous or Endogenous if possible. If exogenous (external blunt trauma) or Lens Induced Uveitis, or Pigmentary Uveitis of the Golden Retriever, Lens Induced Uveitis, etc., then a physical exam and basic laboratory work is all that is necessary (CBC, Chem Panel) just to be sure that the medical therapy is suited to the patient. The full diagnostic work-up must be offered if thought to be endogenous or if no obvious underlying cause; of course use clinical judgment based upon signalment, history, physical examination, geographic exposure and financial concerns (sort list based on above to put the most likely or important tests at the top): Crypotococcosis, Histoplasmosis pending PE, ocular exam and exposure potential. exam and Geographic Travel History Abdominal Ultrasound if PE indicates that Abdominal Ultrasound if PE indicates that Therapy
2. Prednisolone acetate 1% (dogs or cats) or Neopolydexamethasone (dogs): 1 drop 4. Atropine 1%: 1 drop to effect to get pupil dilated (must consider resistance due to 5. Starting doxycycline may be helpful for treatment of possible tick-borne disease until lab tests are back and to help control inflammation 6. Consider starting clindamycin as well in cats 7. Systemic NSAID (pending CBC and Chem Panel first) 8. *Important to check for ulcers prior to topical steroid therapy. if present, use only flurbiprofen BID instead* Caution topical NSAIDs could lead to a worsening of ulcer or collagenase ulcer (melting). Therefore systemic NSAID is often sufficient if labs OK with only the use of a topical antimicrobial and atropine. *if patient is diabetic, topical steroids generally do not cause significant changes in 9. **check IOP first and do not use atropine if elevated or if normal but higher than the normal eye [normal 12 – 26 mm Hg with no more than 6 – 8 mm Hg difference between the two eyes – the uveitis eye should have a lower pressure than the normal eye in acute anterior uveitis!] If the Uveitis eye pressure is greater than 18 – 20 mm Hg that could mean a compromise in aqueous outflow and frank glaucoma could occur with Atropine treatment, especially in a breed predisposed to glaucoma (Bassett Hound, Cocker Spaniel). The systemic NSAID may be sufficient for pain relief. Tropicamide has the same risks as atropine when the IOP is abnormally elevated or of a concern. In addition if the STT is low, consider the need for atropine since atropine will further decrease tear production. If atropine is necessary with low STT, be sure to add in extra ocular lubricants to protect the corneal surface from Lens luxations can be primary (inherited) or secondary. Primary Lens luxations occur in dogs and cats. The Terrier breed is over represented for primary lens Luxation as well as several dog breeds (see list in References section). Secondary lens Luxation occurs as the result of chronic uveitis weakening the lens zonules, lens resorption, buphthalmos causing stretching and breaking the lens zonules, and trauma. Lenses can be luxated anterior or posterior, the anterior lens luxation is the most dangerous in that it can suddenly block the aqueous flow through the pupil causing When there is acute glaucoma and generalized corneal edema, one often needs an index of suspicion that there is an anterior lens luxation. This is where knowing the breeds that are predisposed to lens luxation is helpful and if presented with such a breed and acute glaucoma; either an ocular ultrasound or giving IV mannitol would be the first step. Ocular ultrasound can localize the lens but sometimes it is not clear. IV mannitol will shrink the vitreous and thereby reduce intraocular volume, which will reduce intraocular pressure. When the pressure reduces the cornea will clear and the lens luxation can be see directly. If one were not to recognize that there is an anterior lens luxation and if Xalatan or Travatan were given the glaucoma would worsen since the pupil would become more miotic and further reduce aqueous flow since the lens is in the anterior chamber. In the case of Anterior lens luxation this is a surgical situation however the intraocular pressure needs to be reduced first. A. If IOPs elevated* (> 30mmHg in small animals) – IV Mannitol at 1-
2 GRAMS/kg IV should be given slowly over 30 minutes. Use
cautiously in patients with heart disease, kidney disease or patients
that are dehydrated or hypovolemic.
Be sure to stain for corneal ulceration and treat accordingly
- superficial ulcer: TAB ointment TID-QID should suffice - deep ulcer: § E-collar
§ Ciprofloxacin: 1 drop q2 hours
§ NO Atropine
§ Serum: 1 drop q2 hours
§ Systemic analgesia PRN
§ Systemic NSAID or steroid (not both systemically) Steroid such as dexamethasone SP (0.1-0.2 mg/kg) is preferred since there is likely retinal and optic nerve damage from the acute pressure rise. § Methazolamide: 2 – 5 mg/kg PO BID § Cosopt: 1 drop TID The IOP should start to decrease in about 30 – 60 minutes. *Re-check IOPs over peripheral cornea, try to avoid going right over the lens • Evaluate the "good" eye for sight, signs of lens luxation or subluxation, retinal exam (DO NOT dilate) and measure IOP. DO NOT DILATE THE PUPIL. If there is sign of posterior subluxation (deep anterior chamber, iridodenesis, aphakic crescent and the lens is behind the iris; consider starting on Xalatan once daily as well as a topical ophthalmic steroid such as Neopolydexamethasone or Prednisolone acetate. If the IOP is abnormally elevated the Xalatan should be enough however if there are no signs of lens luxation but the IOP is marginally elevated, start Cosopt TID. The mannitol and methazolamide as part of the therapy for the fellow eye above should markedly improve (reduce IOP) as well in the “good eye”. Clearly an ophthalmologist must remove the anterior luxated lens surgically as soon as possible. Your management as above is to try to keep the IOP in the normal range to preserve retinal and optic nerve function until the lens can be removed. At times, the lens will flip back to the vitreous at which point we can try a PGF2 (Xalatan or Travaprost/Travatan) to close the pupil and keep the lens posterior. If not already, in time the posterior subluxated or completely luxated lenses will develop a complete cataract and secondary LIU (lens induced uveitis). Treatment for the LIU is necessary. Removal of a posterior subluxated or completely luxated lens is not commonly recommended because of the high risk for retinal detachment; however there are select patients that would benefit from this surgery. The term glaucoma means abnormally high eye pressure.
There is normal amount of pressure in the eye to maintain the normal health
and function of the eye; however, if the eye pressure is abnormally elevated
permanent damage to the eye can rapidly occur. The front internal portion of
the eye contains a fluid called aqueous which brings in nutrition to the eye
and carries out waste material from the eye. Aqueous fluid is constantly
circulating in the front portion of the eye starting with the creation of
aqueous behind the iris and then outflow through the pupil finally exiting the
eye internally into the blood stream. The exit or outflow from the eye is
through a sieve like structure called the “angle”. In the normal eye there is a
balanced inflow and outflow of fluid, which results in the maintenance of
normal eye pressure.
Glaucoma always results from fluid not being able to escape from the eye
through the pupil and / or angle.
Glaucoma is a “clinical sign” and not a specific disease. There are many
causes for glaucoma, all of which relate to obstruction of fluid outflow.
Causes of Glaucoma
Causes for restriction of aqueous humor outflow can be due to an inherited
defect in the angle, which can predispose the eyes to restricted outflow.
There are certain breeds of animals that are over-represented for the
development of glaucoma and within these breeds there are known
anatomical angle abnormalities or weak lens ligaments, which could lead
pupil block by a displaced lens. In addition there are situations where
abnormal material in the aqueous, or swelling can obstruct the outflow as in
hemorrhage, inflammation and scarring. Should these latter problems occur
in an eye or eyes with an inherited angle defect, the likelihood of glaucoma
developing is greater.
Glaucoma is a “clinical sign” with many causes for abnormal elevation of
IOP, here are some of the causes:
1.Primary or Breed Associated
2.Uveitis
3.Trauma
4.Lens Luxation
5.Neoplasia
Signs of Glaucoma
Animal with glaucoma can show many signs or combinations of signs such as
a painful, red or cloudy eye, vision loss and abnormal size of the eye.
Irrespective of the clinical signs, measurement of the eye pressure is the
only way to know if glaucoma is present. Various instruments are available
to measure eye pressure and the Tonopen is the most common at this time.
Normal intraocular pressure in an otherwise normal eye for the dog and cat
is approximately 12 – 26 mm Hg with both eyes being with in 6 – 8 mm Hg
of each other. These pressures must be interpreted based on the condition
of the eye and the breed of animal, for example a Bassett Hound with
anterior uveitis in one eye with an IOP of 22 mm Hg with the fellow normal
eye at 14 mm Hg is of a great concern. Even though the uveitis eye has a
pressure in the normal range the pressure is too high for an eye with uveitis
since the eye pressure in uveitis should be lower than normal. In addition
the Bassett Hound can have a congenitally abnormal iridocorneal angle.
Combining the abnormally elevated intraocular pressure with the breed and
the presence of uveitis makes an IOP of 22 mmHg abnormal! The pressure
of 22 mmHg in this patient means the outflow is starting to be obstructed.
Glaucoma can be quite painful especially in the acute phase. Permanent loss
of vision due to retinal and optic nerve damage can occur after only 12 hours
of elevated intraocular pressure.
Treatment of Glaucoma
Treatment of Glaucoma is directed at first trying to determine the cause as
well as reducing the eye pressure. Reduction of the eye pressure is done
with medicine and / or surgery to reduce the production as well as increase
the outflow of aqueous humor.
Medical therapy can be in the form of eye drops and / or oral medications.
Surgical therapy can be either with laser; cryosurgery; and / or shunt
implant or lens removal in the case of a displaced lens.
The ophthalmologist determines the choice of therapy after a thorough
examination of the eye and animal so the optimal therapeutic plan can be
crafted. There is no single standard treatment since glaucoma varies greatly
across patients.
Guidelines for Emergency Therapy
• Determine if there is an anterior lens luxation. Many times it is
difficult to see beyond the cornea due to generalized corneal edema, therefore use of an osmotic diuretic such as Mannitol is helpful in shrinking the vitreous thereby decreasing intraocular volume and subsequent lowering of intraocular pressure. Once the intraocular pressure is reduced the corneal edema will clear allowing you to see if there is an anterior lens luxation. It is important to determine this for two reasons: one – treatment for anterior lens luxation is surgical not medical and two – the use of a strong miotic such as a prostinoid (latanoprost) could further trap the lens in the anterior chamber and even raise intraocular pressure more. Ocular Ultrasound is also useful in determining the position of the lens but this method is sometimes hard to interpret if the examiner is not used to imaging the eye with ultrasound or the probe is not correct for ocular ultrasound. • Posterior subluxated lenses however are often times best treated with a strong miotic such as latanoprost to attempt to trap the lens behind the iris. Care should also be taken to note if the glaucoma is secondary to uveitis since drugs such as miotics/prostinoids will further breakdown the blood aqueous barrier and worsen the uveitis. There comes a time in some patients with uveitis induced glaucoma that latanoprost is the only option and in that case anti-inflammatory drugs must be used as well. Topical nonsteroidals have been reported to increase intraocular pressure a few mm of Hg. Systemic nonsteroidals do not seem to have the same effect. Anticholenergic drugs (atropine and Tropicamide) as well as antihistamines (have an anticholenergic effect) are contraindicated with glaucoma. if you are confident there is no anterior lens luxation OR uveitis:
1. 2 drops Latanaprost (Xalatan) or Travaprost (Travatan) - PGF2 2. Recheck IOP in 30 to 45 minutes. If pupil is not becoming miotic or pressures are not down, repeat Xalatan and IOP check 20-30 minutes later. 3. Start Cosopt or Trusopt eye drops (tid)
4. Start Methazolamide orally
5. If pressure is still not down OR there is anterior uveitis OR if you know
or are worried there may be an anterior lens luxation, DO NOT use
PGF2 analogues or any other drug to make the pupil miotic.
Mannitol, 1-2 GRAMS/kg IV should be given slowly over 30 minutes.
Use cautiously in patients with heart disease, kidney disease or
patients that are dehydrated or hypovolemic.
6. Determine if it is OK to withhold water 1-2 hours since if the animal is allowed to drink during this time the osmotic effect will be lessened. Recheck IOPs in one hour- remember peak effect is about 1.5 hours after Mannitol was given. If no success, determine if Mannitol can be repeated. 7. It is not recommended that an inexperienced person performs paracentesis of the anterior chamber, however, that is often the next step if pressures are still not resolved within a few hours. 8. Once pressure is down, initial following therapy of affected eye: a. Maintenance of Methazolamide: 2-5 mg/kg PO BID b. Cosopt: 1 drop TID c. Maintenance of Xalatan or Travaprost bid Subsequent immediate referral to an ophthalmologist when one is available is the next step for follow-up since some glaucoma patients may also benefit from surgery (Ciliary body ablation with cryosurgery or diode laser and or shunt implantation) to maintain sight! It is not uncommon for glaucoma patients to improve with the emergency therapy but then to soon deteriorate. An ophthalmologist must be involved for management and deciding if adjunctive therapy is needed.
F. If you suspect primary glaucoma (especially in a dog, rarely primary in
the cat), the other eye WILL develop glaucoma so start therapy to keep
pressures down and try to delay onset à Cosopt: 1 drop BID in NORMAL eye
G. If UVEITIS is present (2ndary glaucoma) also start in affected eye:
• Prednisolone acetate 1% or Neopolydexamethasone drops: 1 drop • if ulcerated, a topical antibiotic should be used • Do not use Flurbiprofen in the face of glaucoma since it will increase intraocular pressure. Flurbiprofen will also compromise the healing of a corneal ulcer much like a steroid would therefore topical non-steroidal drugs should not be used in the presence of a corneal ulceration. • Prepare for/begin work-up for primary cause and hold off on systemic steroids but systemic non-steroids can and should be used as long as there is no evidence of liver or kidney problems or bleeding disorders or potential for a bleeding disorder such as thrombocytopenia. • Starting doxycycline may be helpful for treatment of possible tick- borne disease and to help control inflammation • Consider starting clindamycin as well in the cat. • A complete uveitis workup must be done if this is an endogenous Prognosis for GLAUCOMA in general: If eye is blind at presentation there still may be a chance at vision return if the history and or exam indicate that the glaucoma has been present for less than 24 – 48 hours. If the globe is buphthalmic (except Shar Pei and Chow since their globes can enlarge from glaucoma initially and still be sighted) or pressures can not be decreased/maintained to a reasonable level; the next step is aimed at providing pain relief either by Enucleation or intrascleral prosthesis. Certainly if the veterinarian can not determine or is not sure if this is a hopelessly blind and painful eye, a referral to an ophthalmologist immediately should be done before any permanent sight taking procedure is done. If the patient is not a good anesthetic/surgical candidate, intracameral gentamicin injection may be an option but only for a globe that one is sure there is no intraocular tumor or infection. Intracameral gentamicin injection should not be done in the cat since a very malignant tumor could develop (traumatic sarcoma)! The intracameral injection should not be done in eyes that have potential for sight since the gentamicin will permanently blind the eye by damaging the retina. Herpes felis You should be suspicious for herpetic keratitis when a cat presents with an acute corneal ulcer that is punctate or geographic (map shaped) in pattern or shape with no obvious history of trauma, being sprayed in the eye. This should also be a high suspicion in a cat that has had Upper Respiratory Infection history or currently on systemic or topical steroids. THE MOST COMMON CAUSE FOR A SUPERFICIAL NON-HEALING
CORNEAL ULCER (INDOLENT ULCER) IN THE CAT IS HERPES!!!!
Antiviral medications are all virostatic but to date there are no virocidal drugs. The choices are both topical and systemic. The topical drugs come as a drop or ointment. There is only one commercial FDA approved topical drop and the others are compounded by a compounding pharmacy. There is one safe systemic drug for cats that is commercially available. The topical choices are: 1. Idoxuridine drops (available only from a compounding pharmacy): one drop 3 – 4 times per day. Too frequent use will cause severe secondary irritation and it not necessary to use more than 4 times per day. 2. Trifluridine drops (commercially available as generic or trade name [trade name more expensive] or compounded as a preservative free drop from Wedgewood Pharmacy. Trifluridine commercial drops can be very irritating to many cats and in some cats it must be discontinued for that reason. Trifluridine is the best topical antiviral and most effective. Some think the preservative in the commercial product is what causes the irritation therefore some use the preservative free product (short shelf life). The ONE systemic choice is Famciclovir (trade name = FAMVIR
NOTE DO NOT USE ACYCLOVIR
ACYCLOVIR is TOO TOXIC DO NOT USE IN THE CAT EVEN IF YOU SEE IT LISTED IN A VETERINARY TEXT! IT SUPRESSES THE BONE MARROW Famciclovir is a prodrug. Famciclovir enters the body via the GI system and is converted to penciclovir by the liver which is the virostatic agent. Penciclovir then leaves the body via the kidney. Therefore patients put on Famciclovir should have normal kidney and liver function. Famciclovir should be avoided in kittens until further data is obtained and in kittens topical treatment with one of the topicals listed above and L-lysine is the safest. The dose for Famvir is: Adult cat: 250mg - 1/4 tab PO once daily for 20 days (script out 5 tablets) Kitten: 125mg - 1/4 tab PO once daily for 20 days (script out 5 tablets).
In addition to the antivirals we usually use a topical antibiotic that has an
effect against Chlamydia and Mycoplasma (erythromycin, ciprofloxacin or
oxytetracycline [Terramycin].
L-lysine is an aminoacid that blocks the availability of arginine (virus needs
arginine to replicate) and can be useful as a prophylaxis or as part of the
initial therapy. Be sure the L-lysine does not contain any glycol preservatives
since glycol preservatives can cause a Heinz Body Anemia in the cat.
The dose is: 250 mg to 500mg PO BID in adult, 250mg PO BID in kitten (for
life)
If your adult feline patient is being treated appropriately with poor results,
consider starting Famciclovir or Famciclovir can be used in the initial
treatment regimen. Famciclovir can help the cornea/conjunctiva with out the
aid of topical antivirals as well. In some stubborn or more serious cases the use of both is warranted. Recheck with your service or Ophthalmology in 7-10 days unless the corneal ulcer is deep or complicated. Dog breeds over represented for primary lens luxation: The Siamese cat is a breed of cat that is overrepresented for primary lens luxation. Cefazolin Eye Drops

Add 792 mg = 2.4 ml of Cefazolin (330 mg/ml) to 12.6 ml of Artificial Tears.
Exp. = 14 days.
Refrigerate. Shake well. The final concentration is 50 mg/ml.
Details: Reconstitute a 1 gram vial of Cefazolin to 330 mg/ml. Remove 2.4
ml
Aseptically remove the top of a new artificial tear drop bottle (15 ml) and
with a sterile needle and syringe remove 2.4 ml.
Add the 2.4 ml of Cefazolin to the bottle of artificial tears
Final Concentration = 50 mg/ml
Hospital pharmacy could make up several aliquots of 2.4 ml of the 330
mg/ml in a 3 cc syringe and freeze. Then when it comes time to make the
drop just thaw and add to a bottle of artificial tears that has had 2.4 ml of
the tears first removed as above.
Put the cap back on and shake well.

Source: http://www.schostereye.org/Comparative_Ophthalmology/EYE_HOME_PAGE_files/Emergency%20Tips.pdf