Wednesday, April 18, 2007

Lazy me

Monday:

The first case I had in the morning was a dog with progressive vision loss and cloudy eyes for the last month. She's a 5 year old Papillon (the most ADORABLE dogs ever, I love them). Her history is actually of stomach problems, which is more unusual in smaller breed dogs - so that threw us for a loop. She'd never really had any issues before with her eyes. When I looked in here eyes, mostly what I noticed was that she had complete cataracts in both eyes. This means that we can't see in and she can't see out. She can probably tell where shadows are, but not much else. What surprised me was that the owner hadn't reported any changes in the dog's drinking or peeing habits, and what I was seeing was incredibly consistent with diabetic cataracts. I asked the owner twice, Dr P asked again when we got in the room. Apparently any acute onset cataracts can cause separation of the Y-sutures, but the top 5 differentials in dogs are Diabetes. We talked to the owner about surgery, but warned them that because of the dogs ongoing digestive issues that we were a little hesitant about taking her to surgery. We did run bloodwork to check for diabetes and to see if she would even be a tiny bit of a candidate for surgery. She doesn't have diabetes (good), but she does appear to be in kidney failure (bad). This, of course, is my non-clinical-pathologist diagnosis based on anemia, low serum albumin, azotemia and no urine sample.... We called to let the owners know that the dog isn't a candidate for surgery, but that it's pretty important that she get a medical work-up by either her regular DVM or by the internal medicine service here. Also, she had fleas. Ew.

The next case I saw was a 7 year old basset hound that had primary glaucoma. This is an acute onset painful condition in dogs,unlike in humans where the eye pressures rise slowly over time and is generally first noticed when vision begins to be lost. They'd been treating the dog for about 6 weeks, and they had brought the eye pressures down to a nice low good level. It was a pretty straightforward case with good owners :) Unfortunately, eventually this type of glaucoma will become refractory to treatment and the eye will become blind and painful, and probably have to be removed. Double-badness is that this is a developmental eye issue, and the other eye is incredibly likely to also develop primary glaucoma, and eventually the poor dog will probably be blind in both eyes.

The last case that I saw for the day was a recheck from a dog that I'd had the opportunity to see last week! It was the dog with blood in her eye, glaucoma, an ulcer and KCS. We were only treating for the glaucoma and the ulcer over the last week, and while the glaucoma is now under control, the ulcer is still tiny but present. As soon as the ulcer resolves, we can start the dog on topical steroids in addition to the oral steroids to help drop the inflammation and resolve the blood inside the eye and start the dog on optimmune (cyclosporin A) ointment to help to decrease the corneal pigmentation and thickening from the poor tear production. I wish I was on this service longer so that I could continue to follow her treatment - but you do what you can do.

Tuesday:

Yesterday we had just three cases. We started off the morning with a Jack Russell who had excessive tearing in one of his eyes. He was in to have his teeth cleaned, and as long as he was anesthetized we went ahead and evaluated the drainage through his nasolacrimal duct. (Un?)Fortunately, it was normal. So, we have no idea what's up with him. Oh well.

Next we played with J's cat Velvet, a hypothyroid Rex cat (go ahead and google Rex, I'll wait). She was incredibly patient with us and we got to play with both the super duper expensive slit lamp and the headset with the light on it. WOW do those things have a learning curve. I'm glad that I mostly use the handset that I've had years of practice with, as well as that's what most practices that I'm going to be working in have - and it's nice to become comfortable diagnosing with less sophisticated equipment if that's all that will later be available to you.

Then we went to 2 lectures, one on proptosis (don't google this one ~.o) which is when the eye pops out of the socket, and one on exotics. Both were lectures that I went to last year, and not too much had changed. I spent most of the lectures texting Sam and drinking Diet Coke (read: crack).

In the afternoon we had a horse come in who had a history of cloudy eyes. I ended up taking the case. In horses, their eyelids are so strong that you actually have to do a local anesthetic block in order for them to let you completely examine their eye. Dr P did most of the exam, I did most of the writing up and talking to the (young) owner afterwards. First of all, the owner was a senior in high school, and I'm pretty sure not old enough to legally enter into a binding contract.... The woman who drove her and the trailer in was a friend's mom, and had no say. So this teenager was making costly decisions for the horse and spending her mom's money... talk about a weird conversation to have. Anyways, we diagnosed the horse with equine recurring uveitis (moon blindness), but really what the horse had was a secondary uncontrolled glaucoma. We upped the anti-glaucoma drug that the horse was on and added in another drug. The horse had asteroid hylosis (it looks like the starry night screen saver only in the back of the eye), baby cataracts, a pale optic nerve head, and something called Haab's Striae (I'm going to recheck spelling on this). The Striae is when Decemet's membrane (the basement membrane on the inside of the cornea) cracks and it gets all cloudy with edema. It's related to increase pressure inside the eye at some point in time. The other eye was fine, but will probably ultimately also be affected. They don't know how/why it happens, except that it seems to happen to Appaloosa's more often, which this horse was.

Then we had the opportunity to see a cria, a baby alpaca, with lots of developmental defects. I missed most of the explanation, but I do know that the membrane between the nose and the throat never dissolved during development, so she can't eat and breathe at the same time. As a result, she never got colostrum after birth (2d old now) and has a blood infection. Also, she's completely blind, has an eye full of blood, and this kinda neat spiderweb of vessels in the back of the eye. Also, she's kinda neurologic, isn't walking well and has a head tilt. I'm pretty sure they put her down this morning, which is the right thing to do in an animal with so many congenital defects.

We spent the remaining time in the afternoon harassing R's dogs, Samoyeds, that she brought in for our amusement. It was kinda entertaining :) We got to use the toys again, and he had some cool tapetums, very grainy. He probably has early progressive retinal atrophy, because when we set up a maze in the room for him in the very very dim light he ran into a trash can. R's choice about the workup for him, he's a 10ish year old dog :)

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