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Anterior Uvea & LensDavid A. Wilkie DVM, MS, Diplomate ACVO

Professor EmeritusThe Ohio State University

Wilkie.1@osu.edu

The Red, The Cloudy, The Painful

The eye is the “window” to systemic information

The eye has the highest blood flow by weight of any organ

Uveitis

n Clinical Signsn Anteriorn Posterior

Anterior Uveitisn Miosis

Anterior Uveitisn Miosisn Flare

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Anterior Uveitisn Miosisn Flaren Redness

Anterior Uveitisn Miosisn Flaren Rednessn Photophobia

Anterior Uveitisn Miosisn Flaren Rednessn Photophobian Pain

Anterior Uveitisn Miosisn Flaren Rednessn Photophobian Painn Keratic precipitates

Anterior Uveitisn Miosisn Flaren Rednessn Photophobian Painn Keratic precipitatesn Hypotony

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Posterior Uveitisn Chorioretinitis

n Hemorrhagen Vaculitisn Edeman Transudaten Exudate

Anterior Uveitisn Etiologies

n The etiologies of anterior uveitis can be either ocular or systemic.

OcularSystemic

Uveitis

Anterior Uveitisn Ocular Etiologies

n There are only 4 main ocular causes, rule them out first

Anterior Uveitis

n Ocular: n Corneal

ulceration

Anterior Uveitis

n Ocular: n Corneal

ulcerationn Lens-induced

Anterior Uveitis

n Ocular: n Corneal

ulcerationn Lens-inducedn Ocular trauma

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Anterior Uveitisn Ocular:

n Corneal ulceration

n Lens-inducedn Ocular trauman Neoplasia

n primary

Anterior Uveitisn Neoplasia

n Primary vs secondary

Lymphosarcoma

Ciliary adenoma

Anterior Uveitisn Etiologies

n The etiologies of anterior uveitis can be either ocular or systemic.

OcularSystemic

Uveitis

X

Uveitis

BacteremiaSepticemia

ViremiaMycotic

Metastatic neoplasiaAutoimmune

Anterior Uveitisn Systemic Etiologies:

n Bacteremia, viremia, or septicemian Autoimmunen Metastatic neoplasian A complete physical examination is

therefore essential.

Uveitis

n Where does you patient live?n Travel history?

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Canine Uveitisn Idiopathic / Immune-mediated (58%)n Neoplasia (24.5%)n Systemic infectious disease (17.5%)

Massa KL, et al. Causes of uveitis in dogs: 102 Cases (1989-2000) Veterinary Ophthalmology

Blasto Heartworm

Lymphosarcoma

Lyme

Multiple myeloma Erhlichia

Histiocytic Sarcoma

Uveo-Dermatologic Syndrome Erlichia

Blastomycosis Cryptococcosis

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Cryptococcosis

Optic neuritis

Canine Rocky Mountain Spotted Fever

Parasitic MigrationAngiostrongylus

Courtesy of Dr. Tim Knott

Systemic Infectious Disease n Other

n Protothecosisn Aspergillosisn Bartonellosisn Infectious Canine Hepatitisn Brucella canisn Lymes disease

Ocular Oncology

Primary - intraocular Secondary - intraocular

Melanoma LymphosarcomaAdenoma/Adenocarcinoma CarcinomaSpindle cell sarcoma - cat Sarcoma

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COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin

Canine Neoplastic UveitisMultiple Myeloma

Canine Neoplastic UveitisHistiocytic Sarcoma

Lymphosarcoma

Feline Uveitisn Idiopathic / Immune-mediated (33-58%)n Neoplasia (13-23%)n Systemic infectious disease (24-83%)

Feline Infectious Disease• FELV (12%)• FIP (5-19%)• Toxo (5-75%)• FIV (13-21%)• Crypto (2%)• Bartonella

Cat may have more than one of these

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Crypto

FeLV

FIP

FIP

Toxo

FIV

Anterior Uveitis - systemicn Diagnostic Tests

n History - Duration, progression of diseasen Physical examination n Complete blood countn WBC count, Differentialn Platlet count

Anterior Uveitisn Diagnostic Tests

n Biochemical profilen Serologyn Radiologyn Ultrasoundn Cytology/Histopathology

Anterior Uveitis

n Serology – REMEMBER CO-INFECTIONSn Blasto, Histo, Crypto n RMSF, Erlichia canis/platys, Lymes, ICH,

Distempern FeLV, FIV

n Toxo - request IgG, IgM, and Toxo antigen tests

n Bartonellan Leishmania

Uveitis - Things to remembern Canine uveitis

n Idiopathic (58%)n Neoplasia (24.5%)n Systemic infectious

disease (17.5%)

n Feline uveitisn Idiopathic (33-58%)n Neoplasia (13-23%)n Systemic infectious

disease (24-83%)

Therefore, in approximately 50% of cases in both dogs and cats, there is a systemic disease causing the uveitis.

Sequelae of Anterior Uveitisn Anterior &/or posterior synechian Cataractn Glaucoman Blindnessn Phthisis bulbi

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Glaucoma Glaucoman Is the glaucoma primary or secondary?

Glaucoman Is the glaucoma primary or secondary?n Is it acute or chronic?

AcuteChronic

Glaucoma

Intraocular Pressure Determination

n There are 3 specific ways to determine intraocular pressure: n Indentation tonometry n Applanation tonometryn Rebound tonometry

Primary Glaucoman Not associated with

any other ocular disease

n No antecedent cause

Primary Glaucoman This is generally seen in predisposed

breeds:n Poodle, Basset hound, Beagle, Afghann American & English Cocker Spanieln English Springer Spanieln Artic breeds - Husky, Elkhound, Samoyed, etc.n Shar-Pei, Chow Chow, Dalmation, Bouvier, Other

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Primary Glaucoman predisposed to bilateral involvementn bilateral involvement is 50% within 2

years

Primary Glaucoman predisposed to bilateral involvementn bilateral involvement is 50% within 2 yearsn unaffected eye requires preventive therapy

n IOP monitoringn Prophylactic Rx

Secondary Glaucoman The result of some other event in the

eye which results in a decrease in aqueous humor access to the drainage angle or a decrease in outflow

Secondary Glaucoman Etiologies

n Anterior lens luxation

Secondary Glaucoman Gene for PLL identified at University of

Missouri and AHTn Simple recessive traitn Homozygous affected luxated by 4-8 yrn 30% develop glaucoma

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Secondary Glaucoman Etiologies

n Anterior lens luxation

n Synechia

Secondary Glaucoman Etiologies

n Anterior lens luxation

n Uveitis

Hypermature cataract, Lens-induced uveitis, Secondary glaucoma

Why does this happen?

PIFM

Secondary Glaucoman Etiologies - PIFM

n Pre-iridal fibrovascular membranen Uveitis #1n Intraocular Neoplasian Retinal Detachment

PIFM

§Chronic uveitis§Intraocular neoplasia§Retinal detachment/degeneration

Normal Iris

Glaucoma PIFM�s

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RednessDeep corneal vesselsDilated PupilDiffuse Corneal Edema

Acute Primary GlaucomaInfarction secondary to acute glaucoma

Acute Glaucoman Treatment

n Personal preference:n Latanoprostn Mannitol if

latanoprostineffective

n Topical and Systemic CAI

n Referral for Sx

Acute Glaucoman Treatment

n Prostaglandinsn Latanoprost

0.005% (Xalatan)

Miosis

Passive Paracentesis – 30 guage needleAcute Glaucoma

n Treatmentn Topical CAI’s

Dorzolamide reaction

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Acute Glaucoman TransScleral

CycloPhotocoagulation

TSCPSuccess at 1 year:

Canine: 50-60%Equine: >80%

Endocyclophotocoagulation (ECP)

Success at 1 year:Canine: >80%

Lens

Iris

Laser targets Ciliary Processes

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Success at 1 year:Canine: >80%

Ahmed glaucoma shunt

Chronic Glaucoman These are not

emergencies as is the case with the acute patient

n Treatmentn Prosthesisn Enucleationn Pharmacologic

ablation

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Chronic Glaucoman Treatment

n Eviseration with Prosthesis n Remove internal contents of the globen Insert a 19mm silicone spheren Cornea will vascularize over the next 2-4

weeks.

http://youtu.be/lF0bOb42oNs

K9 Intrascleral Prosthesis

K9 ISP 1 week post-op K9 ISP 2 week post-op

K9 ISP 10 week post-op K9 ISP 1 year post-op

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K9 ISP OU 2 yr post-op K9 ISP OD, enucleation OS 1 yr post-op

Cataract Etiology of Cataractsn Hereditaryn Metabolicn Inflammatoryn Traumaticn Toxicn Nutritionaln Radiationn Electric

Canine

Feline

Cataract - locationn Location

n Capsular

Cataract - locationn Location

n Capsularn Cortical

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Cataract - locationn Location

n Capsularn Corticaln Nuclear

Cataract - locationn Location

n Capsularn Corticaln Nuclearn Equatorial

Cataractn Age of onset

n Congenitaln at birth

n Developmentaln < 6yr

n Senilen >6-9yr

Cataract - severityn Progression

n Incipient

Cataract - severityn Progression

n Incipientn Immature

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CataractEquatorial vacuoles - immature

CataractPosterior cortical - immature

Cataract - severityn Progression

n Incipientn Immaturen Mature

CataractMature cataract

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Cataract - severityn Progression

n Incipientn Immaturen Maturen Hypermature

Hypermature

J. Mould

Hypermature

Mature Hypermature

Hypermature

J. Mould

Hypermature with Retinal detachment

Hypermature cataract with LIU Lens induced uveitis

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Lens induced uveitis with secondary glaucomaOcular Ultrasound

Normal eye 10 mHz

Lens

Vitreous

IrisAnterior Chamber

EOM

Cataract Surgeryn Ultrasound

n Vitreous Degenerationn Immature - 2%nMature - 7%nHypermature - 20%

Cataract

Vitreous degeneration

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Vitreous degeneration

Cataract Surgeryn Ultrasound

n Retinal Detachmentn Immature - 2%nMature - 5%nHypermature - 12-15%

Cataract

Retinal detachment

Retinal detachment

Cataract

Retinal detachment

Cataract Surgeryn Electroretinogram

n Awake or under anesthesia

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Photopic

Scotopic

Cataract – why surgery?n 3 options for vision significant cataracts

n 1. Surgery – phacoemulsification + IOLn Best outcome

n 2. Anti-inflammatory treatment; No surgeryn Failure 4x greater than #1

n 3. No treatment; No surgeryn Failure 255x greater than #1

n Failure 65x greater than #2

Lim C, et al: Cataracts in 44 dogs (77 eyes): A comparision of outcomes for no treatment, medical management, or phacoemulsification with IOL. Can Vet J 52:283-288, 2011

When to Refer?n Referral should be

done earlyn We no longer wait

for a mature “ripe” cataract

n Refer early immature and all cataracts that are progressive

Aphakia -14D

EmmetropiaSir HaroldRidley

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1 Year - old DogPhaco -8 sec, 50ml

AcriVet 60V IOL

2 yr post op IOL�s

Questions?