ocular manifestations of systemic disease in dogs
TRANSCRIPT
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OCULAR MANIFESTATIONS OF SYSTEMIC DISEASE
IN DOGS
Dr. Christa Corbett, DVM, MS, DACVOSeptember 17, 2016
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Outline Cardiovascular Hematologic Neurologic Dermatologic Internal medicine
Infectious diseaseEndocrine
Oncologic
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CARDIOVASCULAR
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Systemic hypertension Pathogenesis:
Ischemic necrosis of vessel walls = increased vascular permeability
Patient variation is important to remember, but a sustained systolic BP >180 mmHg will lead to end organ damage
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Systemic hypertension Ophthalmic signs:
Retinal vascular tortuosity (occasionally) Hemorrhages
○ Retinal is most common○ Subconjunctival○ Iris stroma○ Hyphema
Retinal edema or detachment Treatment is targeted at the underlying disease
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HEMATOLOGIC
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Anemia Does not commonly
lead to ocular disease (~10%)
Ophthalmic signs:Conjunctival pallorFocal retinal hemorrhages
○ Due to tissue hypoxia of the vascular walls
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Thrombocytopenia Commonly causes ocular disease
25% have mild ocular signs (focal hemorrhages)16% have severe ocular signs (hyphema)
Ophthalmic signs:Hemorrhages:
○ Retinal is most common○ Subconjunctival○ Iris stroma○ Hyphema
Treatment is targeted at the underlying disease
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Hypertriglyceridemia/Hyperlipidemia Primary (familial)
Miniature schnauzer, Beagle, Briard, Collie, and SheltieAnecdotally in the Capital District Miniature Pinschers
Secondary (secondary to other systemic disease)Hypothyroidism, Diabetes, Pancreatitis most commonCushings, renal or hepatic diseases also rarely possible
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Hypertriglyceridemia/Hyperlipidemia Ophthalmic signs:
Lipemia retinalisLipemic aqueousCorneal lipid
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Hypertriglyceridemia/Hyperlipidemia Ophthalmic signs:
Lipemic aqueous○ Must have alteration in blood-aqueous barrier
(uveitis, intraocular surgical patients)○ Chicken or egg Uveitis started and lipids
leak, or intravascular lipemia causes vascular endotheliitis and increased permeability
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Lipid plaques just about anywhere!
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Hypertriglyceridemia/Hyperlipidemia Treatment:
Treat underlying diseaseThorough diet history
○ (ask the same questions 3-5 times sometimes!!!)
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Hypertriglyceridemia/Hyperlipidemia
STRICT low fat diet○ Royal Canin Gastrointestinal Low Fat
Study by Xenoulis et al JVIM 2011Less than 25g of total fat per 1000 kcal
○ Nutritionist for a low nutritionally balanced fat home cooked diet (U of Tenn)
○ Fruits and Vegetables for treatsLipid binding agents
○ All off-label (as of 2014)○ Omega-3 fatty acids, Fibrates (Gemfibrozil),
Niacin
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Hyperviscosity Causes:
Multiple myeloma, lymphoma, CLL, ehrlichiosis
Ocular findings:Dilated, tortuous retinal vesselsPerivascular edema or infiltrateRetinal hemorrhages (along small arterioles)
Treatment is targeted at the underlying cause
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NEUROLOGIC
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Granulomatous Meningoencephalitis Suspect immune-mediated inflammation of the
meninges and/or brain Optic nerve (+/- retinal) involvement =
blindness, mydriasis Ophthalmic findings:
BlindnessMydriasisPapilledemaPeripapillary hemorrhagesRarely retinal infiltrate or detachment
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Granulomatous Meningoencephalitis Diagnosis:
Neurologic work-up including MRI and CSF Treatment:
Systemic immunosuppression○ Steroids AND Cystosine arabinoside,
Azthioprine, Leflunomide or Cyclosporine
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DERMATOLOGIC
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Autoimmune dermatitides Pemphigus complex diseases Discoid lupus erythematosus Systemic lupus erythematosus
All can lead to facial dermatitis characterized by erosions, ulcers, crusting, scaling and depigmentation
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Parasitic dermatitides Demodex
Ophthalmic findings:○ Alopecia, scaly skin around eyes, lips and
forelegs○ Rarely pruritic unless secondary bacterial
involvement Sarcoptes
Rarely periocular
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Uveodermatologic Syndrome Aka Vogt-Koyanagi-Harada or VKH-
like syndromeHuman version also linked to hearing
loss and meningitis Immune-mediated destruction
of melanocytes Akita is the top breed, but has
been reported in dozens ofothers
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Uveodermatologic Syndrome Ophthalmic findings:
Anterior uveitisChorioretinitis with varying severity
○ Focal regions of subretinal exudate○ Retinal detachments
Loss of choroidal pigment Dermatologic findings:
Vitiligo (skin depigentation) and poliosis (hair depigmentation)
○ Often restricted to face○ Can be ulcerative in nature
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Uveodermatologic Syndrome Diagnosis:
Biopsy of tissue○ Enucleation if glaucomatous and blind○ Dermal biopsy of facial mucocutaneous
junctions
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Uveodermatologic Syndrome Treatment:
Systemic immunosuppressionSteroids AND Azthioprine, Mycophenolate or
CyclosporineTopical anti-inflammatories for anterior
uveitisPrednisolone acetate AND Diclofenac in most
cases+/- Glaucoma medications
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June 26, 2009
September 15, 2009
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June 26, 2009
September 15, 2009
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INTERNAL MEDICINE – Infectious disease
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Tick-Borne disease Lyme
3% incidence of ocular disease in 132 seropositive dogs
Ophthalmic findings:○ Conjunctivitis○ Corneal edema○ Anterior uveitis○ Retinal petechia○ Chorioretinitis○ Retinal detachment○ Orbital disease
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Tick-Borne disease Anaplasma
A. platys = Canine Cyclic Thrombocytopenia○ Ophthalmic findings:
See findings associated with Thrombocytopenia
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Tick-Borne disease Ehrlichia
Ocular lesions can occur in any stage of disease, mostly with E. canis
10-37% of cases have ocular signsOphthalmic findings:
○ Thrombocytopenia findings○ Vasculitis lesions
Anterior or posterior uveitis
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Tick-Borne disease RMSF
81% of cases have ocular signsOphthalmic findings:
○ Thrombocytopenia findings○ Vasculitis lesions
Anterior or posterior uveitis
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Parasitic disease Toxoplasma
Rarely causes ocular disease in dogs Ophthalmomyiasis
Fly larvae penetrate into the eye○ Conjunctival extension○ Penetrating trauma?
May see actual larvae, or can see chronic tracts
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Parasitic disease Ophthalmomyiasis
Subclassifications:○ Externa = Orbital and extraocular ○ Interna anterior = larvae in anterior chamber○ Interna posterior = larvae in posterior segment
Treatment:○ Manual removal if possible○ Organophosphate treatment is controversial,
as dead larvae can incite more inflammation
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Fungal disease Aspergillus
Local disease (nasal mucosa and respiratory) unlikely to cause ocular disease
Disseminated disease can lead to panuveitis, chorioretinitis and retinal detachment
CoccidiomycosisSouthwestern USPanuveitis with disseminated diseaseOften unilateral
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Fungal disease Cryptococcus
Not very common in dogsGranulomatous to
pyogranulomatous chorioretinitis with or without exudative retinal detachment
Optic neuritis possible
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Fungal disease Histoplasma
Chorioretinitis most common, possibly extension to anterior uvea
Optic neuritis
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Fungal disease Blastomycosis
Ocular involvement in 48% of casesOphthalmic findings:
○ Often begins posterior, so early ocular stages aren’t often notedHematologic spread to the fine capillaries of the choroidMild = focal subretinal granulomaSevere = exudative retinal detachment
○ Anterior uveitis is often due to endophthalmitis, organisms are
often not found in anterior uvea
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Fungal disease Blastomycosis
Diagnosis:○ Urine blasto antigen (MiraVista)○ Cytology or biopsy of tissue
Subretinal or vitreous aspirate, enucleation, or biopsy of another distant lesion
○ Serology:AGID test
- 67% sensitivity- 100% specificity
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Fungal disease Blastomycosis
Treatment:○ Long-term azole antifungals (itraconazole has
80% clinical cure rate)Recurrence is common, can be years later
○ +/- oral steroidsNot reported to worsen survival, and may help ocular
disease○ Topical anti-inflammatories ○ +/- Glaucoma meds
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Enucleation???○ Often recommended for blind, painful eyes○ NO proof that the eye can sequester
organisms, so enucleation is considered palliative for pain control, but not essential for survival
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INTERNAL MEDICINE – Endocrine
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Diabetes Ophthalmic findings:
CataractCorneal endothelial cell lossRetinal vascular damage and hemorrhage
○ Note: NOT the same as the proliferative diabetic retinopathy in humans
Decreased corneal sensitivityLow schirmer tear test
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Hypothyroidism Ocular symptoms not directly caused by
hypothyroidism, but associated conditions:KCS
○ Multi-glandular immune-mediated inflammation?Hyperlipidemia can lead to corneal lipid
degeneration, lipemic aqueous or lipemia retinalisNeurologic signs
○ Horner’s, Facial paralysis
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ONCOLOGIC
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Lymphoma Most common metastatic intraocular
tumor 37% of lymphoma cases present with
ocular diseaseAnterior uveitis – 49%Posterior uveitis – 9%Panuveitis – 14%Retinal hemorrhage – 23%Adnexal disease – 6%
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Lymphoma Most common metastatic intraocular tumor 37% of lymphoma cases present with ocular
diseaseAnterior uveitis – 49%Posterior uveitis – 9%Panuveitis – 14%Retinal hemorrhage – 23%Adnexal disease – 6%
Ocular involvement makes this Stage 5, so shorter survival
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Other metastatic disease Mostly carcinomas and sarcomas Malignant melanoma (i.e. ungual) Transmissible venereal tumor Ophthalmic findings:
HyphemaUveitisGlaucoma
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Questions???