Equine Recurrent Pain Photophobia Uveitis ... · equine recurrent uveitis with single port pars...
Transcript of Equine Recurrent Pain Photophobia Uveitis ... · equine recurrent uveitis with single port pars...
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Equine RecurrentEquine RecurrentUveitisUveitis
David A. Wilkie, DVM, MS,David A. Wilkie, DVM, MS,Diplomate ACVODiplomate ACVO
The Ohio State UniversityThe Ohio State University
ERU Clinical Signs - ActiveERU Clinical Signs - Active PainPain PhotophobiaPhotophobia BlepharoedemaBlepharoedema MiosisMiosis Aqueous flareAqueous flare Keratitic Keratitic precipitatesprecipitates HypotonyHypotony ChorioretinitisChorioretinitis
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ERU Clinical Signs - ChronicERU Clinical Signs - Chronic SynechiaSynechia CataractCataract PhthisisPhthisis bulbi bulbi Corpora nigra atrophyCorpora nigra atrophy Peripapillary depigmentationPeripapillary depigmentation GlaucomaGlaucoma Retinal detachmentRetinal detachment BlindnessBlindness
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ERU
Equine Motor Neuron Disease
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Etiology of UveitisEtiology of Uveitis
Primary ocularPrimary ocular Corneal ulcer, cataract, traumaCorneal ulcer, cataract, trauma
Etiology of UveitisEtiology of Uveitis
SystemicSystemic SepticemiaSepticemia ViremiaViremia ParasiticParasitic ImmuneImmune
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UveitisUveitis
Foals with neonatal septicemia areFoals with neonatal septicemia areespecially prone to anterior andespecially prone to anterior andposterior uveitisposterior uveitis
UveitisUveitis Foals with neonatal septicemia are especiallyFoals with neonatal septicemia are especially
prone to anterior and posterior uveitisprone to anterior and posterior uveitis Uveitis in these foals is usually sterileUveitis in these foals is usually sterile
UveitisUveitis Foals with neonatal septicemia are especially proneFoals with neonatal septicemia are especially prone
to anterior and posterior uveitisto anterior and posterior uveitis Uveitis in these foals is usually sterileUveitis in these foals is usually sterile Copious fibrin production may be a consequence ofCopious fibrin production may be a consequence of
anterior uveitis, especially in young foalsanterior uveitis, especially in young foals
UveitisUveitis Foals with neonatal septicemia are especially proneFoals with neonatal septicemia are especially prone
to anterior and posterior uveitisto anterior and posterior uveitis Uveitis in these foals is usually sterileUveitis in these foals is usually sterile Copious fibrin production may be a consequence ofCopious fibrin production may be a consequence of
anterior uveitis, especially in young foalsanterior uveitis, especially in young foals Intracameral Intracameral tissuetissue plasminogen plasminogen activatoractivator
25-75 µg25-75 µg
Fibrinous UveitisFibrinous Uveitis 4 Hours Post TPA4 Hours Post TPA
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Equine Recurrent UveitisEquine Recurrent Uveitis
moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia
Equine Recurrent UveitisEquine Recurrent Uveitis moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia most common cause of blindness in horsesmost common cause of blindness in horses
Equine Recurrent UveitisEquine Recurrent Uveitis moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia most common cause of blindness in horsesmost common cause of blindness in horses Appaloosa has been shown to be a predisposedAppaloosa has been shown to be a predisposed
breedbreed
Equine Recurrent UveitisEquine Recurrent Uveitis moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia most common cause of blindness in horsesmost common cause of blindness in horses Appaloosa has been shown to be a predisposedAppaloosa has been shown to be a predisposed
breedbreed 8 fold increase in risk in the Appaloosa as8 fold increase in risk in the Appaloosa as
compared with other breedscompared with other breeds
Equine Recurrent UveitisEquine Recurrent Uveitis moon blindness, periodicmoon blindness, periodic ophthalmia ophthalmia most common cause of blindness in horsesmost common cause of blindness in horses Appaloosa has been shown to be a predisposedAppaloosa has been shown to be a predisposed
breedbreed 8 fold increase in risk in the Appaloosa as8 fold increase in risk in the Appaloosa as
compared with other breedscompared with other breeds ERU affected AppaloosaERU affected Appaloosa’’s are 4 times more likelys are 4 times more likely
to loose vision than ERU affected non-to loose vision than ERU affected non-AppaloosaAppaloosa’’ss
Equine Recurrent UveitisEquine Recurrent Uveitis
Immune-mediated disease withImmune-mediated disease withnumerous initiating or exacerbatingnumerous initiating or exacerbatingfactorsfactors
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Equine Recurrent UveitisEquine Recurrent Uveitis
Immune-mediated disease withImmune-mediated disease withnumerous initiating or exacerbatingnumerous initiating or exacerbatingfactorsfactors
Frequency and severity of eachFrequency and severity of eachrecurrence are extremely variablerecurrence are extremely variable
Equine Recurrent UveitisEquine Recurrent Uveitis
HorsesHorses seropositive seropositive for for Leptospira Leptospirainterogans serovarinterogans serovar pomona are 13 pomona are 13times more likely to develop ERU thantimes more likely to develop ERU thannon-non-seropositive seropositive horseshorses
Equine Recurrent UveitisEquine Recurrent Uveitis
Horses seropositive for LeptospiraHorses seropositive for Leptospirainterogans serovar pomona are 13interogans serovar pomona are 13timestimes more likely to develop ERU than more likely to develop ERU thannon-non-seropositive seropositive horseshorses
seropositive seropositive horses are 4.5 times morehorses are 4.5 times morelikely to have ERU result in blindnesslikely to have ERU result in blindnessthan non-than non-seropostive seropostive horseshorses
Worst CaseWorst Case Senario Senario
Leptospira interogans serovar Leptospira interogans serovar pomona positivepomona positive
TreatmentTreatment
Suppression of inflammationSuppression of inflammation Control of painControl of pain Prevention of Prevention of sequelaesequelae
Nonspecific TherapyNonspecific Therapy
AtropineAtropine
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Nonspecific TherapyNonspecific Therapy AtropineAtropine NSAIDNSAID’’ss
SystemicSystemic TopicalTopical
Nonspecific TherapyNonspecific Therapy AtropineAtropine NSAIDNSAID’’ss
SystemicSystemic TopicalTopical
CorticosteroidsCorticosteroids SystemicSystemic TopicalTopical
Nonspecific TherapyNonspecific Therapy AtropineAtropine NSAIDNSAID’’ss
SystemicSystemic TopicalTopical
CorticosteroidsCorticosteroids SystemicSystemic TopicalTopical
CyclosporinCyclosporin TopicalTopical IntraocularIntraocular
AtropineAtropine As needed to dilateAs needed to dilate
the pupilthe pupil Not more thanNot more than
4x/day4x/day
SystemicSystemic NSAID NSAID’’ss BanamineBanamine PhenybutazonePhenybutazone AspirinAspirin
CorticosteroidsCorticosteroids Care with topicalCare with topical
use and cornealuse and cornealdiseasedisease
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Topical Topical Cyclosporin Cyclosporin AA Limited cornealLimited corneal
penetrationpenetration
Surgical Management of ERUSurgical Management of ERU
IntravitrealIntravitreal//Suprachoroidal Suprachoroidal placementplacementof a sustained-releaseof a sustained-release cylosporine cylosporineimpregnated deviceimpregnated device
VitrectomyVitrectomy
CyclosporinCyclosporin Gilger Gilger BC, Wilkie DA, et al: Use of anBC, Wilkie DA, et al: Use of an
intravitreal intravitreal sustained-release cyclosporinesustained-release cyclosporinedelivery device for treatment of equinedelivery device for treatment of equinerecurrent uveitis. Am J Vetrecurrent uveitis. Am J Vet Res Res 62:1892-1896,62:1892-1896,20012001
Gilger Gilger BC,BC, Malok Malok E, et al: Lon-term effect onE, et al: Lon-term effect onthe equine eye of anthe equine eye of an intravitreal intravitreal device useddevice usedfor sustained release of cyclosporine A. Vetfor sustained release of cyclosporine A. VetOphthalmol Ophthalmol 3:105-110, 20003:105-110, 2000
Wilkie DA,Wilkie DA, Gemensky Gemensky AJ, et al:AJ, et al: Intravitreal Intravitrealcyclosporin cyclosporin A implantation for equineA implantation for equinerecurrent uveitis. Vetrecurrent uveitis. Vet Ophthalmol Ophthalmol 4:292, 20014:292, 2001
Intravitreal CyclosporinIntravitreal Cyclosporin
Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitrealCsA implantCsA implant
Intravitreal CyclosporinIntravitreal Cyclosporin Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitreal CsACsA
implantimplant decrease the frequency and severity ofdecrease the frequency and severity of
recurrent uveitis episodesrecurrent uveitis episodes
Intravitreal CyclosporinIntravitreal Cyclosporin Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitreal CsACsA
implantimplant decrease the frequency and severity ofdecrease the frequency and severity of
recurrent uveitis episodesrecurrent uveitis episodes 23 horses with a mean follow-up of 1-2923 horses with a mean follow-up of 1-29
months (mean 10.5 +/- SD 7.6 months)months (mean 10.5 +/- SD 7.6 months)
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Intravitreal CyclosporinIntravitreal Cyclosporin Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitreal CsACsA
implantimplant decrease the frequency and severity ofdecrease the frequency and severity of
recurrent uveitis episodesrecurrent uveitis episodes 23 horses with a mean follow-up of 1-2923 horses with a mean follow-up of 1-29
months (mean 10.5 +/- SD 7.6 months)months (mean 10.5 +/- SD 7.6 months) 18/23 (78.2%) remain visual at the time of18/23 (78.2%) remain visual at the time of
follow-up.follow-up.
Intravitreal CyclosporinIntravitreal Cyclosporin Implantation of a 4-Implantation of a 4-ugug/day/day intravitreal intravitreal CsA implantCsA implant decrease the frequency and severity of recurrentdecrease the frequency and severity of recurrent
uveitis episodesuveitis episodes 23 horses with a mean follow-up of 1-29 months23 horses with a mean follow-up of 1-29 months
(mean 10.5 +/- SD 7.6 months)(mean 10.5 +/- SD 7.6 months) 18/23 (78.2%) remain visual at the time of follow-18/23 (78.2%) remain visual at the time of follow-
up.up. Complications include glaucoma and retinalComplications include glaucoma and retinal
detachment, both of which may relate to ERUdetachment, both of which may relate to ERU
Intravitreal CyclosporinIntravitreal Cyclosporin Dorsal approachDorsal approach
Resect Resect conjunctivaconjunctiva Lateral to dorsalLateral to dorsal rectus rectus musclemuscle 6-8 mm posterior to limbus6-8 mm posterior to limbus Stab incisionStab incision Implant device and anchor to scleraImplant device and anchor to sclera
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Placement ofPlacement ofSuprachoroidal Suprachoroidal CsACsA
Matrix implantMatrix implantBrian C.Brian C. Gilger Gilger
NCSUNCSU
Suprachoroidal Suprachoroidal Placement ofPlacement ofMatrix / Reservoir CsA DeviceMatrix / Reservoir CsA Device
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Suprachoriodal Suprachoriodal Placement ofPlacement ofMatrix / Reservoir CsA DeviceMatrix / Reservoir CsA Device
6mm
8-10 mm
7 mm
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VitrectomyVitrectomy
Fruhauf Fruhauf B,B, Ohnesorge Ohnesorge B,B, Deegen Deegen E,E,Boeve Boeve M: Surgical management ofM: Surgical management ofequine recurrent uveitis with singleequine recurrent uveitis with singleport parsport pars plana vitrectomy plana vitrectomy. Vet. VetOphthalmol Ophthalmol 1:137-151, 19981:137-151, 1998
VitrectomyVitrectomy ParsPars plana vitrectomy plana vitrectomy
invasive surgery,invasive surgery,requiring morerequiring moreinstrumentation andinstrumentation andexpertise and isexpertise and isassociated withassociated withsignificantsignificantpost-operativepost-operativevision threateningvision threateningcomplicationscomplications
VitrectomyVitrectomy ParsPars plana vitrectomy plana vitrectomy, as compared with, as compared with intravitreal intravitreal
CsA implantation is a more invasive surgery,CsA implantation is a more invasive surgery,requiring more instrumentation and expertise and isrequiring more instrumentation and expertise and isassociated with significant post-operative visionassociated with significant post-operative visionthreatening complications.threatening complications.
It does appear however to decrease the severity andIt does appear however to decrease the severity andfrequency of ERU episodesfrequency of ERU episodes
VitrectomyVitrectomy ParsPars plana vitrectomy plana vitrectomy, as compared with, as compared with intravitreal intravitreal
CsA implantation is a more invasive surgery,CsA implantation is a more invasive surgery,requiring more instrumentation and expertise and isrequiring more instrumentation and expertise and isassociated with significant post-operative visionassociated with significant post-operative visionthreatening complications.threatening complications.
It does appear however to decrease the severity andIt does appear however to decrease the severity andfrequency of ERU episodesfrequency of ERU episodes
ComplicationsComplications CataractCataract Retinal detachmentRetinal detachment
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PrognosisPrognosis varies according to:varies according to:
severity of uveitis severity of uveitis duration of episodesduration of episodes response to treatmentresponse to treatment frequency of recurrencefrequency of recurrence
reduced in Appaloosa horses and in horsesreduced in Appaloosa horses and in horsesseropositive seropositive forfor Leptospira interogans Leptospira interogansserovar serovar pomonapomona
Questions?