Your Pet's Best Friend

Cataracts in Diabetic Dogs

The appointment schedule says, "Check Eyes".  His owner says, "He was just fine on Friday, and on Saturday he started bumping into things.  He falls off the curb, he can't find the steps.  I put his treat on the floor and he couldn't find it until I put it up where he could smell it."  Well, that sure sounds like he can't see.

When a dog goes gradually blind with age-related cataracts, he becomes accustomed to blurry, ever-worsening vision and learns to compensate.  I have had clients whose dogs had been stone-blind for who-knows-how-long and they never knew it until they rearranged the furniture and Fido plowed into the coffee-table.  They apparently have a pretty decent quality of life.

When dogs go blind suddenly, they are bumping into everything and they are pretty distressed, just as you would be if somebody suddenly turned out all the lights... permanently (or even just a couple of weeks, as in last year's ice storm aftermath). 

So what could make a dog suddenly go blind?  He might have a detached retina from trauma or high blood pressure, but that's pretty uncommon.  He could have an infection or inflammation in his eye that flared up rapidly. We often see that with Blastomycosis, a systemic fungus that's not uncommon in our area.

OR, he could have cataracts, where the lens inside the eye becomes opaque.  This is a close-up of Jackson's eye.  I could see his cataracts from across the room -- the pupil of his eye is all white and sparkly.  The thing is, cataracts don't usually develop overnight.  That is, they don't unless you have Diabetes Mellitus ("sugar diabetes").

"So, Jackson weighs 12 pounds.  Has he lost weight?"  "He weighed 14 pounds four weeks ago."

"Does he drink a lot of water?"   "He is constantly at the water bowl. I can't keep it full."

"How is he feeling?  Any vomiting?"  "He really doesn't feel good.  He doesn't vomit, but he's not eating so well."

And, sure enough, his blood sugar is 434 (should be close to 100), and his urine is full of sugar.  Worse, his urine is full of ketones.  Without adequate insulin, he has been unable to utilize sugars and starches normally for a long time.  So, he has had super-high blood sugar for a long time.  This produces the rapid development of cataracts, maybe not totally overnight, but fast.  [Check out Veterinary Partner for a more thorough explanation.]

Since he couldn't utilize sugar, he had to break down body fat (and probably some muscle and such, as well), hence the rapid weight loss.  Imagine dropping from 140 to 120 in four weeks.  This excessive breakdown of fat has produced a lot of the ketone as byproduct.  It was making Jackson feel kind of sick. [Here's another link to a diabetes discussion on Veterinary Partner.]

Fortunately, he was still eating (though not well) and not vomiting.  Another couple of days and he would have required hospitalization and intensive care.  We started him on insulin, and he was already starting to feel a little better the next morning.  It will probably take a few weeks to really get him regulated, but he should be enjoying life again pretty soon.

Eye problems need attention today, not tomorrow.

I've posted on bug-eyed dogs in the past, and you may recall (or it may be intuitively obvious to you) that they are more susceptible to eye injuries than a dog whose eye is nice and protected back inside the socket (instead of bulging out of it).  This is a rather extreme example.  We did a little work on him to give him a less extreme conformation.

This is a generic Boston Terrier that I googled up for you. Still buggy-eyed, but not nearly so extreme.  Still more susceptible to eye injuries than the average dog.  Today we looked at a Boston Terrier dog who had been holding his left eye shut for THREE WEEKS.  "He just started to open it again yesterday."  I couldn't help myself.  I said, "Three weeks, huh?  What's your hurry, lady?"  This wasn't a good thing to say, as it could make the owner feel dumb, or feel bad.  Then where will you be on getting cooperation?  Nowhere, that's where.  But, as I said, I couldn't help myself.

It turns out that three or four months ago, he had his eye shut for two weeks and then "it got okay".  So, they figured two weeks was probably an acceptable, kind of normal phenomenon.  But when it went to three weeks, well... 

You need to understand: these are nice people and they love their dog and they are not stupid.  For some reason, something just didn't "click" here.  When things sunk in a little, they were very distressed and anxious to fix it. 

 I think of my own eye and how uncomfortable I am when anything gets wrong for even a second: an eyelash, a speck of dust, anything.  This dog had a superfical corneal ulcer.  He had apparently been suffering with this for three weeks.  "Hokey smokes, Bullwinkle!"

Fortunately, the ulcer remained superficial.  With a bug-eyed dog with poor tear film coverage, and reduced ability to fully blink his eye, the ulcer could easily have gone deep and perforated his cornea.  As it is, with very conservative treatment, I expect him to be fully healed (and a lot more comfortable) in just a few days.

I couldn't tell you how many times someone has come in with a squinting, red eye that has had a fox-tail weed awn in it for a week or more.  "I been putting Visine in it."

Man, if there is something wrong with that eye, let's get it looked at pronto.  Your eye is sensitive, and so is your pet's eye.

Corneal Laceration follow-up: the saga continues

I never thought we'd get to this point.  As I wrote previously, I thought he would lose his eye. This guy's owner thinks he can see out of his bum eye.  I'm not convinced that he can see much, maybe light and dark.  The good part is that it doesn't seem to be bothering him.  In the last two weeks, she has thought he felt bad maybe four times.  He's only had four pain pills in that period, because he has acted perfectly fine the rest of the time.

He won't ever have a normal pupil, because his iris is stuck to the back side of his cornea (anterior synechia for you terminology buffs).  Some of his cornea is still opaque, but a lot of it is clear now, revealing what looks like pretty healthy iris tissue.  There are some abnormal (but welcome) blood vessels growing down into his cornea to nourish the healing area.

Things could still go south, but at five weeks past the injury, I'm letting myself get optimistic.

Corneal Laceration follow-up

There are still plenty of ways and plenty of time for this eye to go south, but (incredibly) the dog is keeping his eye open, even in bright light, not squinting, rarely even trying to rub it.

The cornea is not ulcerating (at least it's not taking up fluorescein dye), and the sutures are holding.

Since it was Saturday afternoon when we had to deal with this originally, I wasn't able to obtain a consultation before plunging in.  Since we're still going, I've been able to get a real veterinary ophthalmologist to hold my hand while I'm out of my depth.

He'll never (pretty certainly) ever see out of this eye, but if it just is non-painful, I'll be happy.

Corneal Lacerations

A corneal laceration is a cut or tear through the cornea, the clear part on the front of the eye.  A cat's claw could do it.   Cut all the way through it, and the inside of your eye starts going outside your eye.  Not good.

Stuff outside the eye, like bacteria, can go inside your eye.  Also not good.

Corneal laceration equals "an ocular emergency", meaning you need to get this handled fast or you are going to lose your eye.  You need to see an ophthalmologist right now.

What if you're a dog and the nearest veterinary ophthalmologist is 100 miles away three days a week (200 miles away the other four days)?  You're in deep chop suey, that's what.  Does your local veterinarian have the expertise, the steady hands, and the necessary magnification to see what he's doing?

And does he have this?  This is what it takes to successfully suture the cornea back together. 7-0 means size 0000000 (smaller than 2, 1, 0, 00, etc.).  It means tiny.  It means eensie-weensie-beensie-teensie tiny.  Also, it has to have the special TG140-8 spatula point needle, which is flattened on the end to slip between the microscopically thin layers of the cornea instead of just punching holes in it.  You'll need a really tiny needle-holding-forceps, too, since the needle is a nearly invisible splinter.

I have all that stuff on hand (and it's expensive to just keep lying around), and I've practiced, and I can do it.  Why?  Because some eyes can't wait and many clients cannot or will not travel to the ophthalmologist (and it used to be at least THREE hundred miles).  So I learned.  My problem is this:  I'm still no opthalmologist.

Today I saw a German Shepherd who put his head in front of a moving car last night.  His eye has been bleeding.  Usually this means that the eyelids or the skin around the eye is injured -- it wouldn't be the eye itself that was bleeding... usually.  This guy's eye had a dark red instead of a white, and his cornea was split horizontally about 2/3 of the way across.  His iris had popped forward to plug the hole (which is where the blood had been coming from -- cornea has no blood vessels, iris has lots of them). 

It happened last night.   The cornea wasn't cut.  The eyeball was hit so hard that it burst.  The rest of the eye structures can't be in good shape.  Regardless of who works on this eye, there's a good chance he'll wind up losing it, but they really should see a veterinary ophthalmologist.   Money is an issue, and travel is an issue. So, I sewed his cornea back together and put his iris back inside, and filled him full of anti-inflammatories and antibiotics and we'll see what happens.  He won't see what happens, at least out of that eye.  We'll probably wind up taking it out when it goes to heck, but they wanted to try.

If it does okay, I'll post a follow-up picture.  If not, well...

Haws syndrome - the third eyelid is showing.

Cats and dogs have a third eyelid.   Normally you don't see it, as it stays tucked down in the corner of the eye.  There are tear-producing glands on the back side, and periodically it sweeps across the eye like a windshield-wiper, spreading the tears during the blinking process.   When the outer lids droop, they close together.  When the third eyelid (nictitating membrane) droops, it slides out over the eye.  Most of the time, it just indicates that the pet is feeling crummy.  If an animal is really feeling low, it may cover most of the eye, which leads to frantic phone calls saying "My dog's eyes have rolled back into his head!!"  Of course, that couldn't really happen, as it would rip off your optic nerves when the eyeball rolled around 180 degrees.  The pale third eyelid can resemble the white of the eye (sclera) and that's what fakes people out.

This cat has Haws syndrome (and I can't find out who Dr. Haws was, so let me know if you know.  Of course, it could be called "haws syndrome" because "haw" is another name for the third eyelid.  But that's so mundane... and it doesn't really explain anything.  Why not just call it "third eyelid syndrome"?  But I digress).  The cat seems to feel fine except for the third eyelids showing.  This is believed to be caused by intestinal irritation, as in an animal with a heavy worm burden, or colitis.  The mechanism is poorly understood (I don't think it's the same as "You're so full of ____ your eyes are brown", but since we don't really know...).   

There are lots of write-ups on this if you Google it, but I just happened to get this cool picture, so I'm adding yet another piece of informational flotsam to the web.  The syndrome usually resolves over a few weeks as mysteriously as it appeared.  De-worming may help,if that's what the problem is.  Some may benefit from treatment for intestinal inflammation.  I wouldn't give them an enema to lower the "brown" content, though.

Bug-Eyed Dog is Bug-Eyed no more.

I must say, that though I was a champeen speller in 1967, I'm not even sure that Bug-Eyed is a word.  Maybe a superfluous apostrophe would help it out: Bug-eye'd? ...Nah.

I talked a bit about Bug-eyed dogs in a previous post.  I addressed some of the hazards of the condition, and how to recognize an emergency situation.  I didn't address how to fix these guys, though.

Here we have the "before" picture on this great little Pug, aptly named "Bugsy".  Bugsy is two and a half years old.  A normal dog shows very little sclera (the whites of his eyes, as in "Don't shoot until you see the whites of their eyes, boys.")  You mostly see his iris and pupil.  If you look closely (and do look closely), you can see that the whites (or should I say reds?) of Bugsy's eyes are clearly visible all the way around.  His eyes stick way out of the eyelids.  I reckon they stick out of the sockets a bit, too, but it's his inability to fully close his eyes and blink that's giving him a fit.  His corneas stay too dry, and his body has protected them by growing a thick layer of brown, pigmented tissue on them.  It's sort of like growing a callus on the front of your eyes.  Aside from the discomfort of having your eyes hung out in the breeze, he can't see much through that "callus" on his cornea.

We performed a canthoplasty on Bugsy.  This means that we surgically closed up part of his eyelid opening to make a smaller hole,  This keeps most of his eye covered and moist.  He can blink now.

Yes, it is the same dog, and he still looks like a Pug (though maybe not an extreme Pug). He is much more comfortable now, and much less vulnerable to eye injury.  He still can't see much, though, as his corneas remain covered with pigment.  Now that he has a more normal environment for his eyeball, we have a good chance of dissipating that pigment with cyclosporine topical treatment.  If not, he may have to go to the ophthalmologist for a superficial keratectomy (sort of like peeling the orange, only much more delicate).  We are sure hoping the medicine will work without more surgery.

Bug-Eyed Dogs

I touched on this problem when I discussed weird-looking dogs some time back.  After looking at little Buddy the Boston Terrier today, I feel a need to talk more about it. 

Buddy, like most Boston Terriers, is exophthalmic, or "bug-eyed", as I like to say.  Boston Terriers are not as extreme in this respect as some other breeds, notably the Pug, Shih T'zu, Lhasa Apso, and Pekingese.  All have this in common: they lead with their eyeballs.    Look at yourself in the mirror and you will see that your eye sits back behind the ridge of bone where you wear your eyebrows (unless you've got a serious thyroid problem like the late Marty Feldman).  This is a good thing. If you do a face-plant on something, your eye will be back out of the way.  Not so the little bug-eyed dog.  He has a number-8 eye in a number-5 socket.  This leads to several problems.

First, since his cornea is so prominent, it is easily injured.  Buddy scratched his eye on something unknown yesterday.  His owner didn't see him get hurt, but he noticed him squinting a lot and rubbing it last night.   Second, if you rub it, you can damage it a lot more.   Third, since it sticks out so much, it doesn't get very good tear-film coverage.  That's bad, as the cornea derives most of its nutrition and support from that tear film, since it doesn't have any blood vessels (normally, that is).  So, you have a structure that is in a vulnerable spot, with poor support for healing.   This means that things can go south in a hurry.

A surface scratch on the cornea may heal rapidly on its own, or it may need a little support in the way of infection control with an antibiotic ointment or drops.  For superficial scratches or ulcerations, ointments are best, as they stay in the eye for hours, as opposed to drops which wash out in fifteen minutes or so.  For deeper defects, the ointment is not a good idea, as the glop forms a barrier that actually interferes with healing.  Buddy's cornea has a groove 1/4 inch long, and 1/3 of the depth of his cornea, and this is severe.  If it were any worse, we'd be doing a graft of tissue into the wound to support it.  For the next twenty-four hours, we will be a little more conservative than that, but we'll be treating aggressively.  He will have atropine drops to dilate his pupil, as much of his pain is due to spasms of his iris muscle (like having a cramp inside your eye).  Ciprofloxacin drops to kill bacteria will be used four to six times daily, since they won't stay in there long.  Rimadyl will be given orally, also to help with his pain so that he is less likely to injure himself by rubbing the eye.   We will also use autogenous serum four to six times daily in his eye.  Since his cornea has no blood supply, we take a sample of his own blood and use the liquid part (with the blood cells removed) as an eye drop.  This puts his body's own healing factors right where we need them without having to wait for his body to grow an abnormal blood vessel over to the wound (which it would do, given enough time -- we just can't wait that long).   We'll be following Buddy's progress daily because we don't want him to lose that eye.

Another weird thing that happens with bug-eyed dogs is proptosis globus, meaning that your eyeball is popped out of socket.  Any sudden pressure in the head and neck area can do this.  In veterinary school they told us you could do it by grabbing the scruff of the neck.  I've never seen that, but it doesn't take much.  I once had a Shih T'zu patient who popped his eye out while alone in the home for thirty minutes, and I still don't know how he managed that.  Of course, head trauma will do it, too, and it is frequent complication in dog fights.

When this happens, the optic nerve and blood vessels are severely stretched.  If the eye can be replaced rapidly, vision can sometimes be saved.  We hope to at least save the eye for cosmetic purposes, even if vision is lost.   This needs treatment as soon as possible, as the stretch on the vessels and nerve rapidly causes permanent damage.  The cornea begins to dry out very quickly as well.  It should be obvious that this constitutes an emergency requiring treatment as soon as possible. 

The thing is, with a bug-eyed dog, any injury to the eye rapidly gets worse and should be considered an emergency. A scratch on his eye is not as dramatic as being popped out of socket, but blind is blind.  If you see your pet squinting or rubbing his eye, if you see drainage or the cornea looks cloudy, that is not the time to "wait and see".  There are a lot of one-eyed Pekes and Pugs around.