OCULAR MANIFESTATIONS OF SYSTEMIC DISEASE
IN DOGS
Dr. Christa Corbett, DVM, MS, DACVOSeptember 17, 2016
Outline Cardiovascular Hematologic Neurologic Dermatologic Internal medicine
Infectious diseaseEndocrine
Oncologic
CARDIOVASCULAR
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
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
HEMATOLOGIC
Anemia Does not commonly
lead to ocular disease (~10%)
Ophthalmic signs:Conjunctival pallorFocal retinal hemorrhages
○ Due to tissue hypoxia of the vascular walls
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
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
Hypertriglyceridemia/Hyperlipidemia Ophthalmic signs:
Lipemia retinalisLipemic aqueousCorneal lipid
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
Lipid plaques just about anywhere!
Hypertriglyceridemia/Hyperlipidemia Treatment:
Treat underlying diseaseThorough diet history
○ (ask the same questions 3-5 times sometimes!!!)
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
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
NEUROLOGIC
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
Granulomatous Meningoencephalitis Diagnosis:
Neurologic work-up including MRI and CSF Treatment:
Systemic immunosuppression○ Steroids AND Cystosine arabinoside,
Azthioprine, Leflunomide or Cyclosporine
DERMATOLOGIC
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
Parasitic dermatitides Demodex
Ophthalmic findings:○ Alopecia, scaly skin around eyes, lips and
forelegs○ Rarely pruritic unless secondary bacterial
involvement Sarcoptes
Rarely periocular
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
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
Uveodermatologic Syndrome Diagnosis:
Biopsy of tissue○ Enucleation if glaucomatous and blind○ Dermal biopsy of facial mucocutaneous
junctions
Uveodermatologic Syndrome Treatment:
Systemic immunosuppressionSteroids AND Azthioprine, Mycophenolate or
CyclosporineTopical anti-inflammatories for anterior
uveitisPrednisolone acetate AND Diclofenac in most
cases+/- Glaucoma medications
June 26, 2009
September 15, 2009
June 26, 2009
September 15, 2009
INTERNAL MEDICINE – Infectious disease
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
Tick-Borne disease Anaplasma
A. platys = Canine Cyclic Thrombocytopenia○ Ophthalmic findings:
See findings associated with Thrombocytopenia
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
Tick-Borne disease RMSF
81% of cases have ocular signsOphthalmic findings:
○ Thrombocytopenia findings○ Vasculitis lesions
Anterior or posterior uveitis
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
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
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
Fungal disease Cryptococcus
Not very common in dogsGranulomatous to
pyogranulomatous chorioretinitis with or without exudative retinal detachment
Optic neuritis possible
Fungal disease Histoplasma
Chorioretinitis most common, possibly extension to anterior uvea
Optic neuritis
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
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
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
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
INTERNAL MEDICINE – Endocrine
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
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
ONCOLOGIC
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%
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
Other metastatic disease Mostly carcinomas and sarcomas Malignant melanoma (i.e. ungual) Transmissible venereal tumor Ophthalmic findings:
HyphemaUveitisGlaucoma
Questions???
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